[ CLINICAL COMMENTARY ]

WHITNEY MEIER, DPT, OCS1šHO7DC?PD;H"PhD, MPT2šHE8?DC7H9KI"PT, PhD, OCS3

B;;:?88B;"PT, PhD, ATC3š9>H?IJEF>;HF;J;HI"MD4šF7KB9$B7IJ7OE"PT, PhD, CHT5

Total Knee Arthroplasty: Muscle

Impairments, Functional Limitations, and
Recommended Rehabilitation Approaches
otal knee arthroplasty (TKA) is a commonly performed surgical to normal functional activities such as

T procedure designed to alleviate knee pain and improve function

in individuals with knee osteoarthritis (OA) or rheumatoid
arthritis. More than 450 000 TKAs are performed each year
in the United States and this number is expected to nearly double
by 2020.2,69 Despite the high incidence of knee replacement and the
walking and stair climbing.5,29,42 There-
fore, quadriceps weakness will be the fo-
cus of this clinical commentary.
While the reason for quadriceps weak-
ness is not well understood in this patient
population, it has been suggested that a
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.

availability of postoperative rehabilitative approaches, the resultant
muscle impairments are not well de-
fined and are an understudied area of
postoperative care.1 Of particular inter-
est to rehabilitation professionals is the
acute profound postoperative deficit in
quadriceps muscle strength5,42,52,55,67,70,79,85
J Orthop Sports Phys Ther 2008.38:246-256.
(J78B;') that fails to completely resolve
even years after surgery5,6,29,71,72,85 (J78B;
2). Hamstring strength deficits have also
been reported after TKA surgery5,29,42,51,72;
however, the focus on the quadriceps is
due to the association of the quadriceps
combination of muscle atrophy and neu-
romuscular activation deficits contribute
to residual strength impairments.54 Fail-
ure to adequately address the chronic
muscle impairments is potentially limit-
ing the long-term functional gains that
may be possible following TKA.
Despite the ubiquitous muscle im-
pairments following TKA, long-term
functional outcomes are depicted by

TIODEFI?I0 The number of total knee arthro-
plasty (TKA) surgeries performed each year is pre-
dicted to steadily increase. Following TKA surgery,
self-reported pain and function improve, though
individuals are often plagued with quadriceps
muscle impairments and functional limitations.
Postoperative rehabilitation approaches either are
not incorporated or incompletely address the mus-
cular and functional deficits that persist following
surgery. While the reason for quadriceps weakness
is not well understood in this patient population, it
has been suggested that a combination of muscle
atrophy and neuromuscular activation deficits con-
tribute to residual strength impairments. Failure
to adequately address the chronic muscle impair-
ments has the potential to limit the long-term func-
tional gains that may be possible following TKA.
Postoperative rehabilitation addressing quadriceps
strength should mitigate these impairments and
ultimately result in improved functional outcomes.
The purpose of this paper is to describe these
quadriceps muscle impairments and to discuss
how these impairments can contribute to the
related functional limitations following TKA. We
will also describe the current concepts in TKA
rehabilitation and provide recommendations and
clinical guidelines based on the current available
evidence.
TB;L;BE<;L?:;D9;0 Therapy, level 5.
J Orthop Sports Phys Ther 2008;38(5):246-256.
doi:10.2519/jospt.2008.2715
TA;OMEH:I0 electrical stimulation, rehabilita-
tion, quadriceps strength, total knee arthroplasty,
TKA
both favorable and nonfavorable results.
In general, self-report functional ques-
tionnaires, like the Western Ontario and
McMaster Universities Osteoarthritis
Index (WOMAC) and Medical Outcome
Study 36-Item Short Form Health Sur-
vey (SF-36), show large improvements
following TKA.21,26,33,35,43,45,61,64 Despite
quite dramatic improvements in pain
and perceived function, people who have
had TKA for advanced knee arthritis
have lower scores compared to individu-
als without knee problems.18,59 In contrast
to self-reported outcomes, functional
performance measures, such as a timed

1
Clinical Faculty (Instructor), Department of Physical Therapy, University of Utah, Salt Lake City, UT; Physical Therapist, Department of Orthopedics, University of Utah, Salt Lake
City, UT. 2 Assistant Professor, Department of Physical Therapy, Eastern Washington University, Cheney, WA. 3 Associate Professor (Clinical), Department of Physical Therapy,
University of Utah, Salt Lake City, UT; Physical Therapist, Department of Orthopedics, University of Utah, Salt Lake City, UT. 4 Associate Professor, Department of Orthopedics,
University of Utah, Salt Lake City, UT. 5 Associate Professor, Department of Physical Therapy, University of Utah, Salt Lake City, UT; Adjunct Associate Professor, Department
of Exercise and Sport Sciences, University of Utah, Salt Lake City, UT; Adjunct Associate Professor, Department of Orthopedics, University of Utah, Salt Lake City, UT. Address
correspondence to Dr Paul C. LaStayo, Department of Physical Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108. E-mail: paul.lastayo@health.utah.edu

246 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
 Quadriceps Strength Deficits Compared to Uninvolved Side up to
J78B;'
6 Months Following Total Knee Arthroplasty

H[\[h[dY[ C[Wd7][ J_c[ J[ijCeZ[ ?dlebl[ZDc Kd_dlebl[ZDc :_÷[h[dY[

5
Berman (n = 68) 63 Preoperative Isokinetic 60°/s 35.5 59.9 41
3-6 mo postoperative 39.1 67.0 42
Lorentzen42 (n = 60) 74 Preoperative Isokinetic 30°/s 57.0 67.0 15
3 mo postoperative 55.0 78.0 29
6 mo postoperative 67.0 79.0 15
Preoperative Isokinetic 120°/s 37.0 52.0 29
3 mo postoperative 39.0 52.0 25
6 mo postoperative 42.0 53.0 21
67
Rodgers (n = 20) 68 Preoperative Isokinetic 60°/s 74.6 102.4 27
1.5 mo postoperative 56.9 101.7 44
3 mo postoperative 73.9 103.4 29
Lorentzen42 (n = 60) 74 Preoperative Isometric 75° 66.0 87.0 24
3 mo postoperative 55.0 92.0 40
6 mo postoperative 65.0 92.0 29
Mizner52 (n = 40) 64 Preoperative Isometric 75° 183.7 225.6 19
1 mo postoperative 70.7 222.8 68
2 mo postoperative 95.7 228.1 58
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.

3 mo postoperative 148.8 231.7 36

6 mo postoperative 179.9 228.9 21
* Percent difference calculated: [(uninvolved – TKA)/uninvolved] 100.

stair-climbing or walking test, depict only
modest improvements following TKA,56,81
and substantial residual deficits persist
when compared to age- and sex-matched
healthy comparison groups. These func-
J Orthop Sports Phys Ther 2008.38:246-256.
proved functional ability, and an earlier
return to activity compared to historical
TKA outcomes.52,58,62,72
The purpose of this clinical commen-
tary is 4-fold: (1) to describe the quad-
OA-induced quadriceps weakness con-
sistently exhibit about a 20% strength
deficit compared to healthy age- and sex-
matched cohorts.73 Strength deficits are
ubiquitous in people with advanced knee

tional performance findings are consis-
tent in those with chronic quadriceps
muscle weakness.59,80,85 At times, the defi-
cits in functional performance are quite
pronounced. For example, approximately
three quarters of patients with a knee re-
placement report difficulty negotiating
stairs59 and the average stair-climbing
speed is only half as fast compared to
healthy counterparts.85 Furthermore,
following a peak in functional recovery 2
to 3 years after TKA, there is an acceler-
ated decline in function relative to typical
age-related decrements.66 Physical thera-
py countermeasures seem ideally suited
to mitigate the muscle impairments and
riceps strength impairments related to
TKA and the associated muscle activa-
tion deficits and muscle atrophy; (2) to
explore how these impairments contrib-
ute to functional limitations; (3) to de-
scribe how the current concepts in TKA
rehabilitation are attempting to address
these impairments; and (4) to outline
recommendations and clinical guidelines
for rehabilitation based on the best avail-
able evidence and therapeutic exercise
principles.
GK7:H?9;FIM;7AD;II
<EBBEM?D=JA7
OA who are considering a TKA. Muscle
strength assessments in patients with
TKA are performed with isometric or
slow isokinetic testing speeds. A compila-
tion of these quadriceps strength results
before and after (short- and long-term
follow-up) TKA is provided in J78B;I '
and 2. The most common surgical ap-
proach during a TKA procedure involves
an incision through the extensor mecha-
nism. This surgical approach apparently
compounds preoperative strength deficits
as patients produce less than half of their
preoperative torque values at 1 month
after TKA.52,54,57,79 While quadriceps
strength increases steadily thereafter, sig-

functional limitations following TKA.
Recent descriptions of postoperative re-
habilitation programs with intensive exer-
cise following TKA have reported greater
restoration of quadriceps strength, im-
Q
uadriceps weakness has been
implicated in the development
and progression of knee OA9,74
and is related to a decline in physi-
cal function.15,20,27,32,73 People with knee
nificant changes in strength start taper-
ing off 6 to 12 months following surgery
(J78B;I' and 2). Hence, while isometric
quadriceps strength improves 10% to
20% from preoperative levels following

journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2008 | 247
 [ CLINICAL COMMENTARY ]
Quadriceps Strength Deficits From 6 Months to 13 Years Following
J78B;( Total Knee Arthroplasty: Comparison to the Uninvolved Side or an
Age-Matched Healthy Group*

       :_÷[h[dY[ :_÷[h[dY[
H[\[h[dY[  J_c[ J[ijCeZ[ JA7Dc Kd_dlebl[ZDc >[Wbj^oDc Kd_dlebl[Z >[Wbj^o
Berman5,† 7-12 mo Isokinetic, 60°/s 50.5 71.0 29
13-23 mo 55.9 69.2 13
l24 mo 57.0 68.2 16
Huang29,‡ 6-13 y Isokinetic, 120°/s 48.4 60.7 20
Isokinetic, 180°/s 36.3 49.9 27
Walsh85,§ 1.7 y Isokinetic, 90°/s 57.0 64.5 88.0 12 35
Isokinetic, 120°/s 54.5 63.0 82.0 13 34
Silva72,?? 2.8 y Isometric, 75° of knee flexion 94.7 136.8 31
Berth6,¶ Preoperative Isometric, 90° of knee flexion 66.3 81.9 105.0 19 37
Postoperative (2.8 y) 84.8 79.4 –7 19
* Percent difference calculated: ([healthy – TKA]/healthy)  100.
†
mean age, 63; n = 68.
‡
TKA, n = 36 (mean age, 68); age-match, n = 9 (mean age, 63).
§
TKA, n = 16 (mean age, 65); age-match, n = 10 (mean age, 62).
??
TKA, n = 31 (mean age, 64); age-match, n = 40 (mean age, 63).
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.

¶
TKA, n = 50 (mean age, 66); age-match, n = 23 (mean age, 63).

TKA (85-95 Nm),6,72 strength rarely ever
reaches the value of age-matched healthy
individuals (105-137 Nm)6,72 or the po-
tential isometric or isokinetic strength
levels of the nonoperative knee extensor
muscles (87-232 Nm).5,6,42,52,85 At times,
the amount of residual weakness in in-
dividuals following TKA is substantial in
J Orthop Sports Phys Ther 2008.38:246-256.
pre-existing quadriceps weakness is not
resolved solely by TKA and strength val-
ues post surgery are far from age-matched
normative values.
GkWZh_Y[fiCkiYb[7Yj_lWj_ed
<W_bkh[<ebbem_d]JA7
Quadriceps muscle weakness in patients
imposing a train of high-voltage pulses
with rapid frequency on a MVC. Failure
of voluntary activation of the quadriceps
using burst superimposition is frequently
reported as an index called the central
activation ratio (CAR).36 The CAR is de-
rived by dividing the maximal voluntary
force by the total force achieved via a vol-

that a general strength deficit of 20% or
more is common (J78B;().
Some caution must be exerted when
interpreting results that use the unin-
volved limb as a comparator. Approxi-
mately 40% of patients with unilateral
TKA progress to a TKA in their nonop-
erative lower extremity by 10 years48,65;
hence, the uninvolved knee should prob-
ably not be considered a typically healthy
or unimpaired joint. Consequently, these
estimates of weakness are conserva-
tive.23 Accordingly, when comparing the
long-term strength outcomes of TKA
to healthy age-matched groups,40 the
strength deficit grows to between 30%
and 48%.23,52,53,85 In summary, the quadri-
ceps strength deficits prior to surgery are
greatly compounded early after surgery
and slowly recover to levels only slightly
better than preoperative values. Thus,
with OA of the knee is attributed in part
to failure of voluntary muscle activation
(ie, muscle inhibition).79 The failure of
voluntary activation of skeletal muscle
is defined as the inability to produce all
available force of a muscle despite maxi-
mal voluntary effort.36,75,76 There are 2
common techniques for equating fail-
ure of voluntary activation: twitch in-
terpolation and burst superimposition.
The twitch interpolation procedure is
performed by superimposing a single or
multiple pulses on various intensities of
muscle contractions from 0% (resting)
to 100% maximal voluntary contraction
(MVC). Failure of voluntary activation is
computed as 1 – (superimposed twitch
at MVC/superimposed twitch at rest). A
burst superimposition technique is more
commonly used to determine the levels
of voluntary activation54,57,78 by super-
untary effort plus potential electrically
elicited force (<?=KH;). A CAR of 1.0 de-
notes complete activation of the muscle.36
Healthy older adults (66 to 83 years of
age) with no known knee pathology have
been reported to have a range of CAR val-
ues (0.87-1.00), with an average CAR of
0.96.40,49,77 When interpreting the studies
using superimposed electric stimulation
techniques, it is important to consider
the relationship between the CAR and
voluntary effort.49,76 The calculated CAR
may be lower than the true CAR, and the
failure of voluntary activation may be
overestimated.
Failure of voluntary muscle activa-
tion plays a substantial role in the weak-
ness that is present both before and after
TKA surgery.6,7,23,57,79 Prior to TKA the
average failure of voluntary activation
is more than twice that of healthy older

248 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
 [ CLINICAL COMMENTARY ]
Quadriceps Strength Deficits From 6 Months to 13 Years Following
TABLE 2 Total Knee Arthroplasty: Comparison to the Uninvolved Side or an
Age-Matched Healthy Group*

Difference Difference
Reference Time Test Mode TKA (Nm) Uninvolved (Nm) Healthy (Nm) Uninvolved (%) Healthy (%)
Berman5,† 7-12 mo Isokinetic, 60°/s 50.5 71.0 29
13-23 mo 55.9 69.2 13
l24 mo 57.0 68.2 16
Huang29,‡ 6-13 y Isokinetic, 120°/s 48.4 60.7 20
Isokinetic, 180°/s 36.3 49.9 27
Walsh85,§ 1.7 y Isokinetic, 90°/s 57.0 64.5 88.0 12 35
Isokinetic, 120°/s 54.5 63.0 82.0 13 34
Silva72,?? 2.8 y Isometric, 75° of knee flexion 94.7 136.8 31
Berth6,¶ Preoperative Isometric, 90° of knee flexion 66.3 81.9 105.0 19 37
Postoperative (2.8 y) 84.8 79.4 –7 19
* Percent difference calculated: ([healthy – TKA]/healthy)  100.
†
n = 68 (mean age, 63).
‡
TKA, n = 36 (mean age, 68); age-match, n = 9 (mean age, 63).
§
TKA, n = 16 (mean age, 65); age-match, n = 10 (mean age, 62).
??
TKA, n = 31 (mean age, 64); age-match, n = 40 (mean age, 63).
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.

¶
TKA, n = 50 (mean age, 66); age-match, n = 23 (mean age, 63).

TKA (85-95 Nm),6,72 strength rarely ever
reaches the value of age-matched healthy
individuals (105-137 Nm)6,72 or the po-
tential isometric or isokinetic strength
levels of the nonoperative knee extensor
muscles (87-232 Nm).5,6,42,52,85 At times,
the amount of residual weakness in in-
dividuals following TKA is substantial in
J Orthop Sports Phys Ther 2008.38:246-256.
pre-existing quadriceps weakness is not
resolved solely by TKA and strength val-
ues post surgery are far from age-matched
normative values.
Quadriceps Muscle Activation
Failure Following TKA
Quadriceps muscle weakness in patients
imposing a train of high-voltage pulses
with rapid frequency on a MVC. Failure
of voluntary activation of the quadriceps
using burst superimposition is frequently
reported as an index called the central
activation ratio (CAR).36 The CAR is de-
rived by dividing the maximal voluntary
force by the total force achieved via a vol-

that a general strength deficit of 20% or
more is common (TABLE 2).
Some caution must be exerted when
interpreting results that use the unin-
volved limb as a comparator. Approxi-
mately 40% of patients with unilateral
TKA progress to a TKA in their nonop-
erative lower extremity by 10 years48,65;
hence, the uninvolved knee should prob-
ably not be considered a typically healthy
or unimpaired joint. Consequently, these
estimates of weakness are conserva-
tive.23 Accordingly, when comparing the
long-term strength outcomes of TKA
to healthy age-matched groups,40 the
strength deficit grows to between 30%
and 48%.23,52,53,85 In summary, the quadri-
ceps strength deficits prior to surgery are
greatly compounded early after surgery
and slowly recover to levels only slightly
better than preoperative values. Thus,
with OA of the knee is attributed in part
to failure of voluntary muscle activation
(ie, muscle inhibition).79 The failure of
voluntary activation of skeletal muscle
is defined as the inability to produce all
available force of a muscle despite maxi-
mal voluntary effort.36,75,76 There are 2
common techniques for equating fail-
ure of voluntary activation: twitch in-
terpolation and burst superimposition.
The twitch interpolation procedure is
performed by superimposing a single or
multiple pulses on various intensities of
muscle contractions from 0% (resting)
to 100% maximal voluntary contraction
(MVC). Failure of voluntary activation is
computed as 1 – (superimposed twitch
at MVC/superimposed twitch at rest). A
burst superimposition technique is more
commonly used to determine the levels
of voluntary activation54,57,78 by super-
untary effort plus potential electrically
elicited force (FIGURE). A CAR of 1.0 de-
notes complete activation of the muscle.36
Healthy older adults (66 to 83 years of
age) with no known knee pathology have
been reported to have a range of CAR val-
ues (0.87-1.00), with an average CAR of
0.96.40,49,77 When interpreting the studies
using superimposed electric stimulation
techniques, it is important to consider
the relationship between the CAR and
voluntary effort.49,76 The calculated CAR
may be lower than the true CAR, and the
failure of voluntary activation may be
overestimated.
Failure of voluntary muscle activa-
tion plays a substantial role in the weak-
ness that is present both before and after
TKA surgery.6,7,23,57,79 Prior to TKA the
average failure of voluntary activation
is more than twice that of healthy older

248 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
 MVIC + E
MVIC
300 MVIC 212 N
CAR = = = 0.86
250 MVIC + E 246 N
Force (N)
200
150
100
1 2 3 4 5 voluntary activation was assessed before
Time (s)
<?=KH;$A schematic representation of a quadriceps
force tracing from a maximal voluntary isometric
contraction (MVIC) with an electrically elicited force
during a burst superimposition (MVIC + E). The
central activation ratio (CAR) is derived by dividing
the maximal voluntary force by the total force
achieved during a combined voluntary effort plus any
additional electrically elicited force.
adults.54,63,79 One month following TKA,
the quadriceps activation deficits are
twice from preoperative levels and the av-
erage CAR of people with TKA is roughly
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.
0.75.54,57,79 This level of quadriceps muscle
activation failure is unusually large. As a
reference, those with patellar contusions
have a CAR of 0.8644 and individuals with
acute (6 weeks) anterior cruciate ligament
tears average 0.92.10 As previously stated,
the acute loss of quadriceps strength is
dramatic and the reduction in voluntary
muscle activation accounts for 65% of
the variance in this loss of strength.57,79 In
J Orthop Sports Phys Ther 2008.38:246-256.
fact, voluntary quadriceps activation fail-
ure contributes almost twice as much to
the acute decrease in quadriceps strength
as compared to the amount of quadriceps
muscle atrophy.57,79 Large activation defi-
cits are of particular concern to physical
therapists, as these patients typically ex-
perience only modest strength gains with
exercise interventions.30
It appears that voluntary activation
failure can continue for an extended
period of time after surgery for a subset
of TKA recipients. Gapeyeva and col-
leagues23 reported average quadriceps ac-
tivation levels did not improve in female
TKA recipients from the preoperative
time point until the sixth postoperative
month. Even with upwards of 8 days of
formal rehabilitation, activation levels
remained lower than those of healthy
subjects.23 A similar lack of activation
journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2005 | 249
improvement up to 6 months following
TKA was also reported by Berth et al.7
Twenty patients who were scheduled for
bilateral TKAs had each knee randomly
assigned to receive either a subvastus or
midvastus surgical approach. Quadriceps
surgery, and at 3 months and 6 months
following surgery. All patients underwent
10 days of inpatient rehabilitation and an
additional 4 weeks of outpatient therapy
(though not described in the report).
There was no main effect of time or sur-
gical approach, and quadriceps voluntary
activation levels were well below normal
at all test points. Some others, however,
report some limited activation improve-
ments over time6,78; however, even years
after TKA, activation of the quadriceps
muscle is still significantly lower than for
age-matched healthy controls.6
Poor quadriceps activation is a reha-
bilitation concern because it may blunt
the potential effectiveness of volun-
tary exercise that relates to improving
physical function. Quadriceps activation
failure appears to act as a moderator be-
tween quadriceps strength and physical
function in patients with knee OA. That
is, physical function may be more limited
in those people with quadriceps weak-
ness and a higher degree of activation
failure.21
GkWZh_Y[fi7jhef^o<ebbem_d]WJA7
Sarcopenia, the progressive loss of mus-
cle mass with aging, is a fundamental
contributor to disability in the elderly
population.83 The quadriceps muscle acti-
vation failure present in patients with OA
may be contributing to muscle atrophy,
as neuromuscular inhibition prevents full
muscle activation and potentially blunts
the stimulus necessary to maintain muscle
mass.31 Clinicians sense both activation
failure and atrophy occur in those with
TKA, though there are very few reports
which have assessed muscle size changes
prior to or following TKA. Quadriceps at-
rophy of 5% to 20% has been reported in
the first month after surgery compared to
preoperative values.54,62,67 A recent report
utilizing magnetic resonance imaging
(MRI) assessments on patients who are
awaiting surgery describes a mean quad-
riceps cross-sectional area (CSA) that is
quite small at 42.3 cm2. Additionally, a
10% decrease in muscle size 1 month fol-
lowing TKA (38.2 cm2), compared to the
preoperative values, has been reported.54
When including quadriceps atrophy into
the regression model with activation
failure 85% of the change in quadriceps
strength in the first month after surgery
is explained, though the contribution of
the voluntary activation was nearly twice
the relative contribution of the maximal
cross-sectional area in the regression
equation.54 The atrophy associated with
TKA may be a conservative estimate of
muscle loss, considering the comparisons
that have been made to the uninvolved
or the preoperative values. As noted ear-
lier, the assumption that the uninvolved
extremity is “normal” may not be a valid
comparison in individuals with a history
of OA. The maximal quadriceps CSA
of patients between the ages of 41 to 75
years with a history of OA is 46.1 to 49.5
cm2.24,25 This is considerably less than a
comparative group between the ages of
65 and 81 years, with a maximal CSA of
63.5 to 68.1 cm2.17,22 In summary, most in-
dividuals with a TKA exhibit small quad-
riceps CSA values that are consistent with
long-term OA-induced weakness. As well,
it is still unclear whether muscle strength
and atrophy can return to age-matched
normal values with postoperative reha-
bilitation interventions.
CkiYb[ ?cfW_hc[dji WdZ j^[ H[bWj[Z
<kdYj_edWbB_c_jWj_edi<ebbem_d]JA7
Quadriceps muscle impairments and
lower extremity OA are associated with
functional limitations and slower mobil-
ity performance in older adults.41 The pri-
mary goals of a TKA are to decrease pain,
improve functional mobility, such as walk-
ing and stair climbing, and to promote
return to physical activity. TKA has been
shown to be very effective in reducing the
knee pain associated with arthritis1,34,46;
but 30% of patients report dissatisfac-
 [ CLINICAL COMMENTARY
tion in their physical function 1 year af-
ter surgery.13 Functional outcome scores
reported via questionnaires indicate an
improvement in quality of life following
surgery, but actual physical performance
measures and the individual’s perception
of functional ability remain worse than
the age-matched healthy population.18,59
Individuals 1 year after a TKA surgery
perceived their functional ability to be
approximately 80% of a group of simi-
lar age. In another self-report study only
50% of the TKA recipients considered
their knee function normal compared
to their healthy peers.59 Likewise, quad-
riceps weakness does not correlate well
with patient perceptions of function.52
Self-report scores of physical function
in this population tend to correspond
to what patients experience (like pain
or perceived exertion) when performing
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.
activities, rather than their actual ability
to complete an activity.81,84 Improvement
in self-report physical function is often
most strongly associated with improve-
ments in pain.81
While quadriceps weakness may have
a limited association with perceived
functional ability, it tends to have a
strong relationship with performance.52
Quadriceps weakness in older adults
J Orthop Sports Phys Ther 2008.38:246-256.
has been associated with an increased
fall risk,73 decreased gait speed,5,37,55,60,85
and impaired stair-climbing ability.85
Like with other elderly patient cohorts,
strength is an important predictor of
functional abilities32,39 in patients who
have TKA.53 Once more, bodily pain
scores do not seem to limit functional
performance from 1 month to 6 months
after surgery.52 Even though knee range
of motion (ROM) is also considered to
be important in early phases of therapy
for enhancing functional performance,
there is little evidence that function is
related to knee ROM.50,52 Rehabilitation
following a TKA should still be directed
towards pain control and improving knee
ROM, but a focus on exercises to address
quadriceps muscle impairments appears
necessary to achieve the best functional
abilities.8,52,79
250 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
H;>78?B?J7J?ED
<EBBEM?D=JA7
T
he loss of quadriceps muscle
strength seems to be an inevitable
consequence for people who have
TKA surgery; hence, some have sug-
gested the need for a more aggressive
and long-term postoperative rehabilita-
tion approach.5,72 Quadriceps muscle im-
pairments and corresponding functional
limitations have been addressed in physi-
cal therapy regimens, but the outcomes
to date have generally been suboptimal
and individuals with TKA continue to
perform below age- and gender-matched
controls.18,85 The reports of both preopera-
tive and postoperative TKA rehabilitation
outcomes suggest further modifications to
the physical interventions that are needed
to maximize muscle structure and func-
tional response post surgery. However,
further research, specifically randomized
controlled trials, is warranted to inves-
tigate the effectiveness of strengthening
exercises and manual physical therapy in
individuals after a TKA.
Fh[ef[hWj_l[?dj[hl[dj_edi
Physical countermeasures have been suc-
cessful in improving knee pain, strength,
and joint stability in those with knee
OA who were not yet planning to have
a TKA.11,12,20 For those who go on to a
TKA, preoperative quadriceps strength
is a strong predictor of functional perfor-
mance 1 year after surgery.53 Furthermore,
individuals with more extensive signs of
OA have more quadriceps weakness.73 If
quadriceps weakness could be addressed
prior to TKA surgery, then perhaps pa-
tients might experience a better overall
functional level.
Unfortunately, there is little docu-
mented success in improving the pre-
operative status in those planning a
TKA.19,20,82 Physical therapy interven-
tions prior to TKA have focused on
strengthening, aerobic conditioning,
and educational programs. D’Lima et
al14 compared the effects of preopera-
tive upper and lower extremity strength
]
training, general cardiovascular condi-
tioning exercises, and no intervention
(control group) in individuals before
and after TKA (10 subjects per group).
No significant differences were observed
in the 3 groups at any of the postopera-
tive evaluations. In another study con-
ducted by Rodgers et al,67 10 patients
who underwent 6 weeks of preoperative
physical therapy showed no significant
change in Hospital for Special Surgery
Knee Rating (HSS) scores, knee ROM,
isokinetic knee extension strength, and
walking speed prior to surgery.67 Beaupre
et al4 addressed the combined effect of
preoperative strengthening exercise and
education in 131 subjects scheduled for
TKA. The outcome measures included
gait training with an assistive device, bed
mobility, and transfer training for func-
tional recovery, and the Health-Related
Quality of Life (HRQOL) questionnaire.
The authors reported no significant dif-
ferences in ROM, quadriceps and ham-
string strength, function, or HRQOL
score when compared to a control group
1 year after TKA. Finally, Rooks et al68
found no significant improvements in
self-reported function or performance
measures in those who underwent pre-
operative exercise training compared to
those who did not (22 patients assigned
per group). Considering these findings,
it may be that quadriceps weakness
and functional limitations are recalci-
trant in those about to receive a knee
replacement; however, starting quad-
riceps strengthening earlier (ie, in the
beginning stages of OA) may be the best
approach.53
Feijef[hWj_l[?dj[hl[dj_edi
There is a dearth of available evidence for
determining the best possible postopera-
tive rehabilitation intervention, though
a limited number of reports suggest that
improvements in ROM and strength, a
lowered pain level, and improvements
in independence with activities of daily
living have resulted from such inter-
ventions. The authors of a recent ran-
domized controlled trial comparing a
 and improve functional ability in 40 in-
A Comparison of Therapeutic Exercise dividuals who completed this protocol
J78B;)
Rehabilitation Approaches Following TKA (J78B; )). At 1 month postsurgery, be-
fore treatment was initiated, knee ROM,
 7lhWc_Z_i) C_pd[hWdZIj[l[di52,78 Ce÷[j58 quadriceps strength, and performance
Start of therapy 1 d postoperative 3.5 wk postoperative 8 wk postoperative on the timed up and go (TUG) and stair
Frequency 2 times/d 3 times/wk 1-2 times/wk climb test (SCT) were lower than they
Number of visits (duration) 16 (8 d) 18 (6 wk) 12 (8 wk) were at presurgery. The TKA recipients’
NMES* Yes (6 wk) Yes* No quadriceps strength decreased 62% from
Bike 5-10 min 10-15 min 5-20 min the preoperative value at the first month
Core exercises postsurgery. Following 6 weeks of reha-
Quadriceps sets X X X bilitation, quadriceps strength improved
Hamstring sets X X significantly at each following assessment
Straight-leg raise X X X (2, 3, and 6 months postsurgery). There
Hip abduction X X was also a 21% improvement in the TUG
Standing terminal extension X X and a 40% improvement in the SCT from
Step-ups/-downs X X the preoperative test to 6 months after
AROM/AAROM X X X surgery. Finally, quadriceps strength was
Seated knee extension X correlated with functional performance
Wall squats/standing squats X X measures at all testing sessions and, as
Standing hamstring curl X X quadriceps strength improved, there was
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.

Lunges X an enhancement in functional perfor-

Walking X X mance. This study clearly demonstrates
Non–weight-bearing ROM X X X that the muscle impairments and func-
Ankle pumps X tional limitations can be reversed follow-
Sit-to-stand X ing a TKA.52
Walking backward, marching, side step X There is also some evidence that the
Abbreviations: AAROM, active assistive range of motion; AROM, active range of motion; NMES, neu- addition of neuromuscular electrical
romuscular electrical stimulation; ROM, range of motion; TKA, total knee arthroplasty. stimulation (NMES) to a physical ther-
* NMES parameters: 2500-Hz triangular-wave alternating current (AC), 12-s on-time, 80-s off-time, apy protocol could enhance the speed
2- to 3-s ramp-up time, knee flexed to 60°, 10 isometric contractions, dose set to maximally tolerated
and ultimate recovery of quadriceps
J Orthop Sports Phys Ther 2008.38:246-256.

by the patient, large (7.6  12.7 cm) self-adhesive electrodes placed on motor points of the quadriceps
femoris muscle.
supervised home rehabilitation exercise
program to standard-care control group
reported that individuals with TKA who
received 12 supervised rehabilitation
treatment sessions starting 2 months af-
ter surgery walked longer distances at 1
year after surgery compared to the con-
trol group, and the distance walked in 6
minutes was within 1 standard deviation
of a group of healthy, age-matched indi-
viduals.58 The treatment group showed
an accelerated symptom recovery with
less pain, stiffness, and difficulty per-
forming daily activities compared to the
standard-care group, as reported on the
WOMAC and SF-36 at 6 months after
surgery; but no significant differences
were noted at 1 year postsurgery. A de-
scription and comparison of published
postoperative therapy protocols is pro-
vided in J78B;).
A longitudinal study with a more pro-
gressive and intense rehabilitation pro-
gram instituted earlier after TKA (3-4
weeks postoperatively) and designed
specifically to address the functional
impairments following a TKA has been
repeatedly reported by Mizner and col-
leagues at the University of Delaware.52,78
Their protocol consisted of 3 days of in-
patient physical therapy, followed by 2 to
3 weeks of home physical therapy visits.
At approximately 4 weeks after surgery,
the patients with TKA began 6 weeks (2
to 3 times per week) of outpatient reha-
bilitation. Progressive, high-intensity
volitional exercises were used to increase
lower musculature extremity strength
strength after TKA. In 2 case report se-
ries from the same group, the addition of
high-intensity NMES to the quadriceps
muscle produced strength gains that ex-
ceeded previously published outcomes40,78
(NMES specifications described in J78B;
)). The data were also suggestive of a
positive dose-response relationship for
NMES. Those patients who achieved a
higher percentage of their knee extension
maximal voluntary isometric contrac-
tion torque with NMES contractions had
greater gains in strength.78 These results
suggest that NMES early after TKA may
help resolve quadriceps activation failure
and mitigate quadriceps muscle weak-
ness. When considering the low quadri-
ceps activation in this patient population
early after surgery, the addition of NMES
to augment volitional strengthening ex-
ercises could be a useful adjunct to reha-

journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2005 | 251
 [ CLINICAL COMMENTARY
bilitation, especially for those people who
are very weak.
The addition of NMES even earlier
than 4 weeks may also be beneficial. A
randomized control study by Avramidis
et al3 investigated the effect of 4 hours
per day of NMES (40 Hz, 300 μs) to the
vastus medialis, commencing on postop-
erative day 2 and continuing for 6 weeks
following surgery. This resulted in im-
proved walking speed, though no changes
were noted in the HSS or in an index of
physiological cost.3 A recent case report
also describes the use of NMES, initiated
on postoperative day 2 for a 6-week pe-
riod, and reported strength gains in the
first month after surgery compared to
preoperative values.51 In summary, out-
patient rehabilitation after a TKA seems
to be superior to no intervention at all.
These studies suggest that muscle impair-
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.
ments and functional limitations can be
reversed following a TKA. But additional
research is necessary to determine the
optimal mode, intensity, and duration of
physical therapy needed to mitigate the
muscle impairments and related func-
tional limitations following a TKA.
H;9ECC;D:7J?EDI7D:JA7
9B?D?97B=K?:;B?D;I
J Orthop Sports Phys Ther 2008.38:246-256.
T
he recommendations and clini-
cal guidelines described below are
derived from the best available
evidence, but additional research, spe-
cifically randomized controlled trials, is
needed to optimize short- and long-term
outcomes for individuals after a TKA.
Nevertheless, recipients of TKA should
respond favorably to similar therapeutic
exercise guidelines as suggested by the
American College of Sports Medicine
(ACSM) for older individuals.47 That is,
progressive resistive training of major
muscle groups (especially of the lower
extremities) should be performed 2 to
3 times per week and aerobic training 3
times per week for 30 to 40 minutes.38
The aerobic training for those with a
TKA, however, should include walking
on flat ground initially, adding hills, and
252 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
]
J78B;* 1999 Knee Society Survey 28
  H[Yecc[dZ[Z7Yj_l_j_[i<ebbem_d]JejWbAd[[7hj^hefbWijo
Aerobics (low impact) Square dancing
Bicycling (stationary) Walking
Bowling Golf
Croquet Horseshoes
Ballroom dancing Shooting
Jazz dancing Shuffleboard
Swimming Horseback riding
  7Yj_l_j_[iH[Yecc[dZ[ZM_j^Fh[l_eki;nf[h_[dY[
Bicycling (road) Skiing (cross country)
Canoeing Skiing (stationary)
Hiking Tennis (doubles)
Rowing Weight machines
Speed walking
  7Yj_l_j_[iDejH[Yecc[dZ[Z
Racquetball Football
Squash Gymnastics
Rock climbing Lacrosse
Soccer Hockey
Singles tennis Basketball
Volleyball Jogging
Handball
  De9edYbki_ed
Fencing Downhill skiing
Roller blade/inline skating Weight lifting
negotiating stairs. Higher-level aerobic Therapeutic exercise guidelines fol-
exercises that minimize impact to the lowing a TKA are traditionally focused
knee, such as swimming, cycling, water on the control of pain and swelling, while
aerobics, and power walking, are also rec- improving ROM and functional mobility.
ommended. Recreational activities with More progressive, high-intensity exer-
high joint loads, such as skiing, tennis, cises may be necessary to address lower
and hiking, should be performed with extremity muscle size, activation and
caution and only occasionally. TKA recip- strength deficits, along with functional
ients are strongly cautioned to avoid even mobility early following surgery. The use
the lowest-level impact recreational and of NMES along with an exercise program
athletic activities until their quadriceps has demonstrated improved quadriceps
and hamstring muscles are rehabilitated strength and activation and is recom-
sufficiently.28 Specific recommendations mended early in a rehabilitation program.
derived from the 1999 Knee Society Sur- Resistance training (60% of the 1-repeti-
vey28 have been used to develop a con- tion maximum) has been demonstrated
sensus recommendation for athletics to induce increases in strength in the
and sports participation for those with a elderly.16 Therefore, it may be necessary
TKA (J78B;*). Despite these guidelines, to increase the lower extremity strength
many TKA recipients still experience training to at least that level of intensity
significant difficulty in performing ac- for 1 to 3 sets of 10 to 20 repetitions to
tivities that require higher-level mobility overcome the recalcitrant muscle impair-
skills commensurate with recreational ments which may be present 6 months
activities.18,59 to 1 year following TKA. The 7FF;D:?N
 provides specific guidelines relative to
a progressive rehabilitative program for
those following a TKA. These recommen-
dations are used to address the pertinent
muscle impairments in addition to en-
hancing mobility.
The protocols mentioned by Moffet
and colleagues58 and the investigations
from Snyder-Mackler’s laboratory at the
University of Delaware40,55,78 are combined
with the ACSM guidelines into 4 phases
and the timelines are a guide for progres-
sion into the next phase. Modifications to
this program are instituted immediately
if adverse knee joint reactions (eg, pain,
swelling) occur. Decreasing the intensity,
frequency, and duration of the resistance
exercise typically resolves any adverse
knee response. In phase I following a
TKA, patients receive home health or out-
patient physical therapy 2 to 3 times per
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.
week for 2 to 3 weeks after inpatient dis-
charge. The emphasis of physical therapy
in this phase is on edema management,
improving ROM, starting a strengthening
program, and improving functional inde-
pendence. At approximately 3 to 4 weeks
postsurgery, or when goals are met, the
patients start phase II, which consists of
outpatient physical therapy 2 to 3 times
per week for 4 to 6 weeks. Augmentation
J Orthop Sports Phys Ther 2008.38:246-256.
of the quadriceps muscle’s activation fol-
lowing TKA should be emphasized early
in this rehabilitation phase to help re-
store quadriceps muscle strength. Physi-
cal therapy treatments should employ the
concepts of progressive high-intensity vo-
litional exercises with NMES to increase
strength and quadriceps muscle activa-
tion.52,58,78 At 10 to 12 weeks postopera-
tive or when the criteria for progression
are met, such as ROM from 5° or less to
110° or greater, minimal pain and edema,
and voluntary quadriceps muscle control,
patients progress to phase III of the re-
habilitation program. Phase III includes
a semi-independent period of 4 to 8 in-
clinic visits over 3 to 4 weeks, with a goal
to improve strength and progress to an
independent phase (phase IV), with clini-
cal follow-up visits for another 8 weeks.
In addition to a warm-up and functional
journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2005 | 253
endurance exercises, this program places
an emphasis on strengthening resistance
exercises for the lower extremity. In an
attempt to mitigate the muscle impair-
ments, progressive, moderately high-
resistance exercises are used. Most often
individuals with TKA can increase the
intensity of exercise after 3 sets of 10 rep-
etitions are completed correctly without
undue fatigue.
IKCC7HO
M
uscle impairments that ex-
ist following a TKA may persist
for years. Improving quadriceps
strength may mitigate these impair-
ments and result in improved functional
outcomes. An emphasis on muscle weak-
ness countermeasures, like resistance
exercises and NMES, is needed. Further
research is required to determine the op-
timal exercise prescription that can safely
augment the return to near-normal lev-
els of activity and function for individuals
who had TKA surgery. T
H;<;H;D9;I
 '$ NIH Consensus Statement on total knee re-
placement December 8-10, 2003. J Bone Joint
Surg Am. 2004;86-A:1328-1335.
 ($ American Academy of Orthopaedic Surgeons.
Arthroplasty and Total Joint Replacement Pro-
cedures: 2003. Available at: http//www.aaos.
org/wordhtml/research/stats/arthroplasty_re-
cent.htm. Accessed 2003.
 )$ Avramidis K, Strike PW, Taylor PN, Swain ID. Ef-
fectiveness of electric stimulation of the vastus
medialis muscle in the rehabilitation of patients
after total knee arthroplasty. Arch Phys Med
Rehabil. 2003;84:1850-1853.
 *$ Beaupre LA, Lier D, Davies DM, Johnston DB.
The effect of a preoperative exercise and educa-
tion program on functional recovery, health
related quality of life, and health service utiliza-
tion following primary total knee arthroplasty. J
Rheumatol. 2004;31:1166-1173.
 +$ Berman AT, Bosacco SJ, Israelite C. Evaluation
of total knee arthroplasty using isokinetic test-
ing. Clin Orthop Relat Res. 1991;106-113.
 ,$ Berth A, Urbach D, Awiszus F. Improvement of
voluntary quadriceps muscle activation after
total knee arthroplasty. Arch Phys Med Rehabil.
2002;83:1432-1436.
 -$ Berth A, Urbach D, Neumann W, Awiszus F.
Strength and voluntary activation of quadri-
ceps femoris muscle in total knee arthroplasty
with midvastus and subvastus approaches.
J Arthroplasty. 2007;22:83-88. http://dx.doi.
org/10.1016/j.arth.2006.02.161
 .$ Brander VA, Mullarkey CF, Stulberg SD. Re-
habilitation After Total Joint Replacement for
Osteoarthritis: An Evidence-Based Approach.
Philadelphia, PA: Hanley & Belfus, Inc; 2001.
 /$ Brandt KD, Heilman DK, Slemenda C, et al. A
comparison of lower extremity muscle strength,
obesity, and depression scores in elderly
subjects with knee pain with and without ra-
diographic evidence of knee osteoarthritis. J
Rheumatol. 2000;27:1937-1946.
'&$ Chmielewski TL, Stackhouse S, Axe MJ, Snyder-
Mackler L. A prospective analysis of incidence
and severity of quadriceps inhibition in a con-
secutive sample of 100 patients with complete
acute anterior cruciate ligament rupture. J
Orthop Res. 2004;22:925-930. http://dx.doi.
org/10.1016/j.orthres.2004.01.007
''$ Deyle GD, Allison SC, Matekel RL, et al. Physical
therapy treatment effectiveness for osteoarthri-
tis of the knee: a randomized comparison of
supervised clinical exercise and manual therapy
procedures versus a home exercise program.
Phys Ther. 2005;85:1301-1317.
'($ Deyle GD, Henderson NE, Matekel RL, Ryder
MG, Garber MB, Allison SC. Effectiveness
of manual physical therapy and exercise in
osteoarthritis of the knee. A randomized, con-
trolled trial. Ann Intern Med. 2000;132:173-181.
')$ Dickstein R, Heffes Y, Shabtai EI, Markowitz E.
Total knee arthroplasty in the elderly: patients’
self-appraisal 6 and 12 months postoperatively.
Gerontology. 1998;44:204-210.
'*$ D’Lima DD, Colwell CW, Jr., Morris BA, Hardwick
ME, Kozin F. The effect of preoperative exercise
on total knee replacement outcomes. Clin Or-
thop Relat Res. 1996;174-182.
'+$ Ettinger WH, Jr., Afable RF. Physical disability
from knee osteoarthritis: the role of exercise
as an intervention. Med Sci Sports Exerc.
1994;26:1435-1440.
',$ Evans WJ. Exercise training guidelines for the
elderly. Med Sci Sports Exerc. 1999;31:12-17.
 '-$ Ferri A, Scaglioni G, Pousson M, Capodaglio P,
Van Hoecke J, Narici MV. Strength and power
changes of the human plantar flexors and knee
extensors in response to resistance training in
old age. Acta Physiol Scand. 2003;177:69-78.
'.$ Finch E, Walsh M, Thomas SG, Woodhouse LJ.
Functional ability perceived by individuals fol-
lowing total knee arthroplasty compared to age-
matched individuals without knee disability. J
Orthop Sport Phys Ther. 1998;27:255-263.
'/$ Fitzgerald GK. Therapeutic exercise for
knee osteoarthritis: considering factors that
may influence outcome. Eura Medicophys.
2005;41:163-171.
(&$ Fitzgerald GK, Oatis C. Role of physical therapy
in management of knee osteoarthritis. Curr
Opin Rheumatol. 2004;16:143-147.
('$ Fitzgerald JD, Orav EJ, Lee TH, et al. Patient
 [ CLINICAL COMMENTARY
quality of life during the 12 months following
joint replacement surgery. Arthritis Rheum.
2004;51:100-109. http://dx.doi.org/10.1002/
art.20090
(($ Frontera WR, Hughes VA, Fielding RA, Fiatarone
MA, Evans WJ, Roubenoff R. Aging of skeletal
muscle: a 12-yr longitudinal study. J Appl
Physiol. 2000;88:1321-1326.
()$ Gapeyeva H, Buht N, Peterson K, Ereline J,
Haviko T, Paasuke M. Quadriceps femoris mus-
cle voluntary isometric force production and
relaxation characteristics before and 6 months
after unilateral total knee arthroplasty in
women. Knee Surg Sports Traumatol Arthrosc.
2007;15:202-211. http://dx.doi.org/10.1007/
s00167-006-0166-y
(*$ Gur H, Cakin N, Akova B, Okay E, Kucukoglu
S. Concentric versus combined concentric-
eccentric isokinetic training: effects on func-
tional capacity and symptoms in patients with
osteoarthrosis of the knee. Arch Phys Med
Rehabil. 2002;83:308-316.
(+$ Gur H, Cakin N. Muscle mass, isokinetic torque,
and functional capacity in women with osteoar-
thritis of the knee. Arch Phys Med Rehabil.
2003;84:1534-1541.
(,$ Hartley RC, Barton-Hanson NG, Finley R,
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.
Parkinson RW. Early patient outcomes after
primary and revision total knee arthroplasty.
A prospective study. J Bone Joint Surg Br.
2002;84:994-999.
(-$ Hassan BS, Mockett S, Doherty M. Static
postural sway, proprioception, and maximal
voluntary quadriceps contraction in patients
with knee osteoarthritis and normal control
subjects. Ann Rheum Dis. 2001;60:612-618.
(.$ Healy WL, Iorio R, Lemos MJ. Athletic activity
after total knee arthroplasty. Clin Orthop Relat
Res. 2000;65-71.
J Orthop Sports Phys Ther 2008.38:246-256.
(/$ Huang CH, Cheng CK, Lee YT, Lee KS. Muscle
strength after successful total knee replace-
ment: a 6- to 13-year followup. Clin Orthop
Relat Res. 1996;147-154.
)&$ Hurley MV, Jones DW, Newham DJ. Arthrogenic
quadriceps inhibition and rehabilitation of
patients with extensive traumatic knee injuries.
Clin Sci (Lond). 1994;86:305-310.
)'$ Hurley MV, Newham DJ. The influence of ar-
throgenous muscle inhibition on quadriceps
rehabilitation of patients with early, unilat-
eral osteoarthritic knees. Br J Rheumatol.
1993;32:127-131.
)($ Hurley MV, Scott DL. Improvements in quad-
riceps sensorimotor function and disability
of patients with knee osteoarthritis following
a clinically practicable exercise regime. Br J
Rheumatol. 1998;37:1181-1187.
))$ Jones CA, Voaklander DC, Johnston DW,
Suarez-Almazor ME. Health related quality of
life outcomes after total hip and knee arthro-
plasties in a community based population. J
Rheumatol. 2000;27:1745-1752.
)*$ Jones DL, Westby MD, Greidanus N, et al. Up-
date on hip and knee arthroplasty: current state
of evidence. Arthritis Rheum. 2005;53:772-780.
254 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy
http://dx.doi.org/10.1002/art.21465
)+$ Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The
functional outcomes of total knee arthroplasty.
J Bone Joint Surg Am. 2005;87:1719-1724.
http://dx.doi.org/10.2106/JBJS.D.02714
),$ Kent-Braun JA, Le Blanc R. Quantitation of
central activation failure during maximal vol-
untary contractions in humans. Muscle Nerve.
1996;19:861-869. http://dx.doi.org/10.1002/
(SICI)1097-4598(199607)19:7&lt;861::AID-
MUS8&gt;3.0.CO;2-7
)-$ Kroll MA, Otis JC, Sculco TP, et al. The relation-
ship of stride characteristics to pain before and
after total knee arthroplasty. Clin Orthop Relat
Res. 1989;191-195.
).$ Kuster MS. Exercise recommendations after
total joint replacement: a review of the current
literature and proposal of scientifically based
guidelines. Sports Med. 2002;32:433-445.
)/$ Landers KA, Hunter GR, Wetzstein CJ, Bamman
MM, Weinsier RL. The interrelationship among
muscle mass, strength, and the ability to per-
form physical tasks of daily living in younger
and older women. J Gerontol A Biol Sci Med
Sci. 2001;56:B443-448.
*&$ Lewek M, Stevens J, Snyder-Mackler L. The use
of electrical stimulation to increase quadriceps
femoris muscle force in an elderly patient
following a total knee arthroplasty. Phys Ther.
2001;81:1565-1571.
*'$ Ling SM, Xue QL, Simonsick EM, et al. Transi-
tions to mobility difficulty associated with lower
extremity osteoarthritis in high functioning
older women: longitudinal data from the Wom-
en’s Health and Aging Study II. Arthritis Rheum.
2006;55:256-263. http://dx.doi.org/10.1002/
art.21858
*($ Lorentzen JS, Petersen MM, Brot C, Madsen
OR. Early changes in muscle strength after total
knee arthroplasty. A 6-month follow-up of 30
knees. Acta Orthop Scand. 1999;70:176-179.
*)$ Mahomed NN, Liang MH, Cook EF, et al. The
importance of patient expectations in predict-
ing functional outcomes after total joint arthro-
plasty. J Rheumatol. 2002;29:1273-1279.
**$ Manal TJ, Snyder-Mackler L. Failure of voluntary
activation of the quadriceps femoris muscle
after patellar contusion. J Orthop Sports Phys
Ther. 2000;30:655-660; discussion 661-653.
*+$ March LM, Cross MJ, Lapsley H, et al. Out-
comes after hip or knee replacement surgery
for osteoarthritis. A prospective cohort study
comparing patients’ quality of life before and
after surgery with age-related population
norms. Med J Aust. 1999;171:235-238.
*,$ Martin SD, Scott RD, Thornhill TS. Current
concepts of total knee arthroplasty. J Orthop
Sports Phys Ther. 1998;28:252-261.
*-$ Mazzeo RS, Cavanagh P, Evans WJ, et al. Ameri-
can College of Sports Medicine Position Stand.
Exercise and physical activity for older adults.
Med Sci Sports Exerc. 1998;30:992-1008.
*.$ McMahon M, Block JA. The risk of contral-
ateral total knee arthroplasty after knee
replacement for osteoarthritis. J Rheumatol.
]
2003;30:1822-1824.
*/$ Miller M, Flansbjer UB, Downham D, Lexell J.
Superimposed electrical stimulation: assess-
ment of voluntary activation and perceived
discomfort in healthy, moderately active older
and younger women and men. Am J Phys
Med Rehabil. 2006;85:945-950. http://dx.doi.
org/10.1097/01.phm.0000247648.62957.19
+&$ Miner AL, Lingard EA, Wright EA, Sledge CB,
Katz JN. Knee range of motion after total
knee arthroplasty: how important is this
as an outcome measure? J Arthroplasty.
2003;18:286-294. http://dx.doi.org/10.1054/
arth.2003.50046
+'$ Mintken PE, Carpenter KJ, Eckhoff D, Kohrt
WM, Stevens JE. Early neuromuscular electri-
cal stimulation to optimize quadriceps muscle
function following total knee arthroplasty:
a case report. J Orthop Sports Phys Ther.
2007;37:364-371. http://dx.doi.org/10.2519/
jospt.2007.2541
+($ Mizner RL, Petterson SC, Snyder-Mackler
L. Quadriceps strength and the time course
of functional recovery after total knee
arthroplasty. J Orthop Sports Phys Ther.
2005;35:424-436.
+)$ Mizner RL, Petterson SC, Stevens JE, Axe MJ,
Snyder-Mackler L. Preoperative quadriceps
strength predicts functional ability one year
after total knee arthroplasty. J Rheumatol.
2005;32:1533-1539.
+*$ Mizner RL, Petterson SC, Stevens JE, Vanden-
borne K, Snyder-Mackler L. Early quadriceps
strength loss after total knee arthroplasty. The
contributions of muscle atrophy and failure
of voluntary muscle activation. J Bone Joint
Surg Am. 2005;87:1047-1053. http://dx.doi.
org/10.2106/JBJS.D.01992
++$ Mizner RL, Snyder-Mackler L. Altered loading
during walking and sit-to-stand is affected
by quadriceps weakness after total knee ar-
throplasty. J Orthop Res. 2005;23:1083-1090.
http://dx.doi.org/10.1016/j.orthres.2005.01.021
+,$ Mizner RL, Snyder-Mackler L. Patients percep-
tions do not match functional performance or
clinical presentation after total knee arthro-
plasty. 10th World Congress on Osteoarthritis.
Prague, Czech Republic: 2006.
+-$ Mizner RL, Stevens JE, Snyder-Mackler L.
Voluntary activation and decreased force
production of the quadriceps femoris muscle
after total knee arthroplasty. Phys Ther.
2003;83:359-365.
+.$ Moffet H, Collet JP, Shapiro SH, Paradis G, Mar-
quis F, Roy L. Effectiveness of intensive reha-
bilitation on functional ability and quality of life
after first total knee arthroplasty: A single-blind
randomized controlled trial. Arch Phys Med
Rehabil. 2004;85:546-556.
+/$ Noble PC, Gordon MJ, Weiss JM, Reddix RN,
Conditt MA, Mathis KB. Does total knee re-
placement restore normal knee function? Clin
Orthop Relat Res. 2005;157-165.
,&$ Ouellet D, Moffet H. Locomotor deficits before
and two months after knee arthroplasty. Ar-
 thritis Rheum. 2002;47:484-493. http://dx.doi.
org/10.1002/art.10652
,'$ Parent E, Moffet H. Comparative responsiveness
of locomotor tests and questionnaires used to
follow early recovery after total knee arthro-
plasty. Arch Phys Med Rehabil. 2002;83:70-80.
,($ Perhonen M, Komi P, Hakkinen K, von Bonsdorff
H, Partio E. Strength training and neuromus-
cular function in elderly people with total knee
endoprosthesis. Scand J Med Sci Sports.
1992;2:234-243.
,)$ Peterson SC, Mizner RL, Snyder-Mackler L.
Quadriceps Femoris Muscle Recovery After
Total Knee Arthroplasty. 9th World Congress on
Osteoarthritis. Chicago, IL: 2004.
,*$ Ritter MA, Albohm MJ, Keating EM, Faris PM,
Meding JB. Comparative outcomes of total joint
arthroplasty. J Arthroplasty. 1995;10:737-741.
,+$ Ritter MA, Carr KD, Keating EM, Faris PM. Long-
term outcomes of contralateral knees after uni-
lateral total knee arthroplasty for osteoarthritis.
J Arthroplasty. 1994;9:347-349.
,,$ Ritter MA, Thong AE, Davis KE, Berend ME,
Meding JB, Faris PM. Long-term deterioration
of joint evaluation scores. J Bone Joint Surg Br.
2004;86:438-442.
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.
,-$ Rodgers JA, Garvin KL, Walker CW, Morford
D, Urban J, Bedard J. Preoperative physical
therapy in primary total knee arthroplasty. J
Arthroplasty. 1998;13:414-421.
,.$ Rooks DS, Huang J, Bierbaum BE, et al. Effect
of preoperative exercise on measures of func-
tional status in men and women undergoing to-
tal hip and knee arthroplasty. Arthritis Rheum.
2006;55:700-708. http://dx.doi.org/10.1002/
art.22223
,/$ Roos EM, Toksvig-Larsen S. Knee injury
and Osteoarthritis Outcome Score (KOOS)
J Orthop Sports Phys Ther 2008.38:246-256.
- validation and comparison to the WOMAC
in total knee replacement. Health Qual
Life Outcomes. 2003;1:17. http://dx.doi.
org/10.1186/1477-7525-1-17
-&$ Rossi MD, Brown LE, Whitehurst M. Early
strength response of the knee extensors
H;>78?B?J7J?ED=K?:;B?D;I<EBBEM?D=7JEJ7BAD;;7HJ>HEFB7IJO
F^Wi[?0>ec[^[Wbj^ehekjfWj_[djf^oi_YWbj^[hWfo(#)j_c[if[hma"(#)ma 4. Straight-leg raise
Goals:
1. Increase range of motion (ROM)
2. Decrease edema and pain
3. Gait training
4. Independence with activities of daily living (ADLs)
Exercises:
1. Seated or supine knee active range of motion (AROM)
2. Alternated ankle dorsiflexion and plantar flexion
3. Quadriceps sets
journal of orthopaedic & sports physical therapy | volume 38 | number 5 | may 2008 | 255
during eight weeks of resistive training after
unilateral total knee arthroplasty. J Strength
Cond Res. 2005;19:944-949. http://dx.doi.
org/10.1519/R-14333.1
-'$ Rossi MD, Brown LE, Whitehurst M. Knee exten-
sor and flexor torque characteristics before
and after unilateral total knee arthroplasty. Am
J Phys Med Rehabil. 2006;85:737-746. http://
dx.doi.org/10.1097/01.phm.0000233178.22621.
a5
-($ Silva M, Shepherd EF, Jackson WO, Pratt JA,
McClung CD, Schmalzried TP. Knee strength
after total knee arthroplasty. J Arthroplasty.
2003;18:605-611.
-)$ Slemenda C, Brandt KD, Heilman DK, et al.
Quadriceps weakness and osteoarthritis of the
knee. Ann Intern Med. 1997;127:97-104.
-*$ Slemenda C, Heilman DK, Brandt KD, et al.
Reduced quadriceps strength relative to body
weight: a risk factor for knee osteoarthritis in
women? Arthritis Rheum. 1998;41:1951-1959.
http://dx.doi.org/10.1002/1529-
0131(199811)41:11<1951::AID-ART9>3.0.CO;2-9
-+$ Snyder-Mackler L, De Luca PF, Williams
PR, Eastlack ME, Bartolozzi AR, 3rd. Reflex
inhibition of the quadriceps femoris muscle
after injury or reconstruction of the anterior
cruciate ligament. J Bone Joint Surg Am.
1994;76:555-560.
-,$ Stackhouse SK, Dean JC, Lee SC, Binder-
MacLeod SA. Measurement of central activation
failure of the quadriceps femoris in healthy
adults. Muscle Nerve. 2000;23:1706-1712.
http://dx.doi.org/10.1002/1097-
4598(200011)23:11<1706::AID-
MUS6>3.0.CO;2-B
--$ Stackhouse SK, Stevens JE, Lee SC, Pearce KM,
Snyder-Mackler L, Binder-Macleod SA. Maxi-
mum voluntary activation in nonfatigued and
fatigued muscle of young and elderly individu-
als. Phys Ther. 2001;81:1102-1109.
-.$ Stevens JE, Mizner RL, Snyder-Mackler L.
Neuromuscular electrical stimulation for
quadriceps muscle strengthening after bilateral
7FF;D:?N
5. Hamstring sets
6. Standing leg curls
7. Seated knee extension
8. Supported single standing for balance
9. Repeated sit-to-stand transfer training
10. Ambulating with appropriate assistive device
Modalities:
1. Ice 2-3 times per d, with lower extremity elevated for 20-30 min
total knee arthroplasty: a case series. J Orthop
Sports Phys Ther. 2004;34:21-29.
-/$ Stevens JE, Mizner RL, Snyder-Mackler L. Quad-
riceps strength and volitional activation before
and after total knee arthroplasty for osteoar-
thritis. J Orthop Res. 2003;21:775-779. http://
dx.doi.org/10.1016/S0736-0266(03)00052-4
.&$ Stickles B, Phillips L, Brox WT, Owens B,
Lanzer WL. Defining the relationship between
obesity and total joint arthroplasty. Obes Res.
2001;9:219-223.
.'$ Stratford PW, Kennedy DM. Performance mea-
sures were necessary to obtain a complete pic-
ture of osteoarthritic patients. J Clin Epidemiol.
2006;59:160-167. http://dx.doi.org/10.1016/j.
jclinepi.2005.07.012
.($ van Baar ME, Assendelft WJ, Dekker J,
Oostendorp RA, Bijlsma JW. Effectiveness
of exercise therapy in patients with os-
teoarthritis of the hip or knee: a systematic
review of randomized clinical trials. Arthritis
Rheum. 1999;42:1361-1369. http://dx.doi.
org/10.1002/1529-0131(199907)42:7<1361::AID-
ANR9>3.0.CO;2-9
.)$ Volpi E, Nazemi R, Fujita S. Muscle tissue
changes with aging. Curr Opin Clin Nutr Metab
Care. 2004;7:405-410.
.*$ Walker DJ, Heslop PS, Chandler C, Pinder IM.
Measured ambulation and self-reported health
status following total joint replacement for the
osteoarthritic knee. Rheumatology (Oxford).
2002;41:755-758.
.+$ Walsh M, Woodhouse LJ, Thomas SG, Finch E.
Physical impairments and functional limita-
tions: a comparison of individuals 1 year after
total knee arthroplasty with control subjects.
Phys Ther. 1998;78:248-258.
@
CEH;?D<EHC7J?ED
WWW.JOSPT.ORG
 [ CLINICAL COMMENTARY ]
7FF;D:?N9EDJ?DK;:

Criteria for progression to exclusively outpatient physical therapy: Exercise progression:

a. AROM approaching 90° of knee flexion
b. Minimal pain/swelling
c. Independence in mobility in and out of the home
F^Wi[??0EkjfWj_[djf^oi_YWbj^[hWfo(#)j_c[if[hma"*#,ma d. Increase wall slides to 60° and to 90°
Warm-up (15-20 min):
1. Exercise bike (10-15 min), start with forward and backward pedaling with no
resistance until there’s enough knee ROM for a full revolution. Seat height may
be lowered for progression of ROM
2. Seated or supine knee AROM (flexion and extension)
3. Alternated ankle dorsiflexion and plantar flexion
4. Passive knee extension stretch
5. Patellar and knee mobilizations
Specific strengthening (10-15 min), 1-3 sets of 10 repetitions:
1. Neuromuscular electrical stimulation (NMES) to augment quadriceps muscle
activation. NMES parameters: 2500-Hz triangular-wave alternating current,
Downloaded from www.jospt.org by 49.36.128.243 on 01/26/20. For personal use only.
a. Exercises are to be progressed once the patient can complete 3 sets of 10
reps of the exercise correctly and feels maximally fatigued
b. Add 0.2- to 1.5-kg weights to the exercises
c. Increase step height if showing good concentric/eccentric control
F^Wi[???0I[c_#_dZ[f[dZ[djf^Wi['j_c[f[hmaehX_m[[abo"*#,m[[ai
Exercises:
1. Continue all exercises in phase I as a home exercise program or a gym
membership
Warm-up (15-20 min):
1. Seated or supine knee AROM (flexion and extension)
2. Alternated ankle dorsiflexion and plantar flexion
3. Passive knee extension and hamstring stretch
4. Exercise bike or treadmill walking (perceived exertion should be light)
Strengthening (20 -30 min, 1-3 sets of 10-20 reps of any of the following):
1. Leg press varying working ROM*

12-s on-time, 80-s off-time, 2- to 3-s ramp-up time, knee flexed to 60°, 10 2. Leg extension: ROM, 90°-0° or 90°-30° for extension*
isometric contractions, dose set to maximally tolerated by the patient, large 3. Standing or sitting leg curls*
(7.6  12.7 cm) self-adhesive electrodes placed on the motor points of the 4. Standing heel raises*
quadriceps femoris muscle 5. 4-way hip machine or (rubber band or ankle weights for resisted hip ROM)*
6. Sit-to-stand free weights in hands
2. Quadriceps sets
7. Weight-bearing exercises with emphasis on eccentric control
3. Straight-leg raises (assistance as needed, goal to perform without a knee
8. Upper extremity strength training optional
extension lag)
*Use a 5- or 10-repetition maximum to determine 60%-70% resistance of 1-rep-
4. Hip abduction (side lying) etition maximum
5. Standing leg curls *Machine weights
J Orthop Sports Phys Ther 2008.38:246-256.

6. Seated knee extension

Functional exercises (10-15 min):
7. Standing terminal knee extension from 45° to 0°
1. Step-ups 5-15 cm or climbing a flight of stairs
Functional exercises (10-15 min): 2. 45° to 90° wall slides or sit-to-stands, hold 5-10 s
1. Step-ups, 5-15 cm, or climbing a flight of stairs 3. Walking backward, side step, march, or crossover steps
2. 45° wall slides or sit-to-stands Endurance exercises (5-20 min, alternate between walking and biking):
3. Walking backward, side step, march, or crossover steps 1. Walking, change speed and incline
4. Walking through an obstacle course 2. Biking
5. Gait training emphasis on heel strike and push-off at toe-off
Criteria for progression:
Endurance exercises (5-20 min): Exercises are to be progressed once the patient can complete 3 sets of 10 reps
1. Walking of the exercise correctly and feels maximally fatigued
2. Stationary cycle Exercise progression:
a. Reassess 65%-70% of maximal effort biweekly to determine progression of
Cool-down (10 min):
resistance
1. Ice and compression as needed
b. Increase step height if showing good concentric/eccentric control
2. Gentle stretching and ROM
c. Increase wall slides to 60° and to 90°
Criteria for progression: F^Wi[?L0?dZ[f[dZ[djf^Wi[l_i_jiiY^[Zkb[Z'j_c[%maehX_m[[abo\eh.ma"ehWi
a. Voluntary quadriceps muscle control or 0° knee extension lag d[[Z[Z"jeh[Wii[iiijh[d]j^"HEC"WdZ\kdYj_ed"WdZjefhe]h[ii[n[hY_i[i
b. AROM 0° to greater than 105° of knee flexion Exercises (continue all exercises, 1-3 sets at 10-20 reps, as a home program or
c. Minimal to no pain and swelling a gym membership 2-3 times/wk)

256 | may 2008 | volume 38 | number 5 | journal of orthopaedic & sports physical therapy