Original Article

Kneeling after Total Knee Arthroplasty

Raj M. Amin, MD1 Vikram Vasan2 Julius K. Oni, MD3

1 Department of Orthopaedic Surgery, The Johns Hopkins University,
Baltimore, Maryland
2 Krieger School of Arts and Sciences, The Johns Hopkins University,
Baltimore, Maryland
3 Division of Adult Reconstruction, Department of Orthopaedic
Surgery, The Johns Hopkins University, Baltimore, Maryland
Address for correspondence Julius K. Oni, MD, Department of
Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins
Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224
(e-mail: joni1@jhmi.edu).

J Knee Surg

Abstract The ability to kneel is one of the many patient goals after total knee arthroplasty (TKA).
Few studies have addressed patients’ ability to kneel after TKA as a primary outcome.
Given the altered biomechanics of the knee after TKA, the various implant designs, and
multiple surgical approaches, there is a need to further understand the patient’s

Downloaded by: Universidad de Barcelona. Copyrighted material.

kneeling ability after TKA. We evaluated the available literature on this topic to help to
guide postoperative care recommendations. Biomechanical data show that the load
borne by the patellofemoral joint is elevated significantly at all flexion angles, whereas
tibiofemoral articulation pressures are elevated only at 90 to 120 degrees of flexion.
However, these increased pressures are rarely borne by prosthetic knees because
Keywords patients often avoid kneeling after TKA. In patients who do kneel after surgery, data
► deep flexion show that increased range of motion promotes improved kneeling performance.
► double-stance Targeted interventions to encourage kneeling after TKA, including preoperative
kneeling education, have not shown an ability to increase the frequency with which patients
► kneeling kneel after TKA. Reasons for patient avoidance of kneeling are multifaceted and
► outcomes complex. There is no biomechanical or clinical evidence contraindicating kneeling after
► total knee TKA. There are insufficient data to recommend particular prosthetic designs or surgical
arthroplasty approaches to maximize kneeling ability after surgery. Musculoskeletal health care
► single-stance providers should continue to promote kneeling to allow patients to achieve maximum
kneeling clinical benefit after TKA.

Total knee arthroplasty (TKA) is both the most common joint
replacement surgery and an effective long-term treatment
for arthritic degeneration of the native knee joint.1 In addi-
tion to pain relief, patients expect functional improvements
after TKA in the domains of walking, stretching exercises,
and gardening.2
Though kneeling is not well understood after TKA com-
pared with the aforementioned domains, > 50% of patients
name performance of this activity as a primary goal after
undergoing TKA.2 Therefore, the ability to kneel is a core
Dr. Julius K. Oni's ORCID is orcid.org/0000-0003-1846-2353.
component of patient satisfaction after TKA. Kneeling is
essential to activities of daily living, culture, occupation,
and hobbies.3 Moreover, kneeling on the native knee joint
increases risk of osteoarthritis and is a routine activity for a
substantial number of TKA candidates.4,5 It is critical for
orthopaedic surgeons to understand the effect of kneeling on
TKA outcomes and vice versa.2,6
Although robust clinical data show the benefits of TKA,
most studies of functional outcomes after TKA report on
pain, ability to walk, and use of stairs and have medium- to
long-term follow-up.7–14 As a primary clinical outcome,
kneeling after TKA is reported minimally.4,15–24 Studies

received Copyright © by Thieme Medical DOI https://doi.org/

August 30, 2018 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0038-1676801.
accepted New York, NY 10001, USA. ISSN 1538-8506.
November 11, 2018 Tel: +1(212) 584-4662.
Patients’ Ability to Kneel after TKA Amin et al.
that evaluate kneeling as an outcome after TKA consistently
show that only 20 to 25% of patients are content with their
postoperative ability to kneel.15,21,25,26 However, the cause
of this dissatisfaction is complex. To date, risk factors for
organic-kneeling difficulty include concomitant spinal
pathology, scar position, pain, and skin hypoesthesia.3,27
However, knee stability has not been implicated in the
inability to kneel.24 Psychological factors and patient educa-
tion are increasingly reported as primary drivers of patients’
inability to kneel or dissatisfaction with kneeling after
surgery.4,28
Given the lack of consensus regarding factors affecting
kneeling and outcomes associated with kneeling after TKA,
we evaluated the available empirical and kinematic data to
guide postoperative recommendations.4
Biomechanics of Kneeling
Tricompartmental fluoroscopic examination of the effect of
kneeling on total knee prostheses shows that > 90% of
prostheses show no substantial sagittal plane translation
during kneeling.29 However, condylar lift-off of > 1 mm is
observed in 84% of prostheses during kneeling.29 An under-
standing of the biomechanics and impact of kneeling on TKA
prostheses requires differentiation of the forces that occur in
the patellofemoral and tibiofemoral articulations. Addition-
ally, it requires differentiation of the pressures borne at both
of these articulations during upright kneeling (90 degrees of
knee flexion; ►Fig. 1A) versus flexed kneeling (> 110 degrees
of knee flexion; ►Fig. 1B) and during single-stance kneeling
(►Fig. 1C) versus double-stance kneeling (►Fig. 1D).
During kneeling, patellofemoral contact pressures are
markedly increased between 75 and 90 degrees of flexion
in the native knee.3 Similarly, in patients who have under-
gone TKA, upright kneeling places substantial stress on the
prosthesis because the anterior aspect of the knee bears
nearly 97% of the body’s weight.30,31 Upright kneeling
increases the patellofemoral force by 123% during double-
stance kneeling and 245% during single-stance kneeling.31
Fig. 1 Illustration of (A) upright kneeling, (B) flexed kneeling, (C) single-stance kneeling, and (D) double-stance kneeling.
The Journal of Knee Surgery
These increases in patellofemoral pressure are caused by
abrupt changes in patellar tilt from the application of an
exterior force (ground) to the tibial tubercle.32
In native knees, patellofemoral pressure during flexed
kneeling is substantially lower than during upright kneeling
because of the predominance of tendofemoral contact, as
opposed to patellofemoral contact.3 After TKA, flexed kneel-
ing reduces the overall load on the prosthetic knee by 50%.
However, the patellofemoral articulation does not follow
this pattern. At flexion angles of 90 to 120 degrees of
patellofemoral articulation, pressure remained significantly
increased compared with flexion of < 90 degrees3 and
exceeded the yield strength of ultrahigh molecular weight
polyethylene in one study.31 However, no clinical reports
have shown patellofemoral polyethylene failure caused by
kneeling. At flexion angles > 120 degrees, there is a marked
reduction in patellofemoral pressure. At 135 degrees of
flexion, patellofemoral articular pressure is nearly equiva-
lent to the baseline patellofemoral load during nonflexion
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activities, except for single-stance kneeling in which articu-
lation pressure remains significantly elevated.31 This overall
reduction in patellofemoral articular pressure is likely
caused by primary loading of the tibial tuberosity with
minimal patella-ground contact at high-flexion angles.3,4,31
Given the reduction in pressure at angles greater than
flexed kneeling, maximal range of motion after TKA may
help reduce patellofemoral wear. Moreover, maximum
postoperative flexion should be encouraged because some
data suggest significant clinical benefits, including improve-
ment of kneeling ability with high-flexion as opposed to
conventional TKA prosthetic design.23 However, this finding
is not reported consistently.33
With respect to tibiofemoral articulation, upright kneel-
ing significantly increases contact pressures during single-
and double-stance kneeling in both cruciate-retaining and
posterior-stabilized implants compared with native knees.3
However, unlike in the patellofemoral compartment,
increased flexion range decreases the load on tibiofemoral
contact pressures much lower than 120 degrees. Compared

with native knees, knees that have undergone TKA have
significantly higher tibiofemoral contact pressures during
flexed kneeling in only the lateral compartment at
120 degrees. This effect disappears at 135 degrees, likely
because of greater contact area resulting in force
dispersion.3,34
Although tibiofemoral pressures increase significantly
during upright kneeling, associations among kneeling,
increased tibiofemoral pressure, and faster polyethylene
wear are not documented. This lack of data regarding
increased wear has been attributed to the similar area of
maximal contact and stress of the tibiofemoral junction
during upright kneeling, which is similar to that during other
deep-flexion weightbearing activities, including rising from
a chair and climbing stairs.35 Additionally, data suggest that
deep-flexion activities, such as kneeling, increase posterior
polyethylene contact pressure, though it should be noted
that this is reported in TKA prostheses made of high-flexion
polyethylene.18 Moreover, studies suggest that, during
kneeling, despite a posteriorly directed sheer force (ground)
on the tibia, the femoral component rolls posteriorly rather
than translating anteriorly, relative to the tibia. This suggests
that kneeling does not induce linear polyethylene wear from
component translation.29,36,37 Overall, there is insufficient
evidence to suggest that kneeling promotes faster or differ-
ent modes of polyethylene wear than do similar weightbear-
ing flexion activities. Some studies suggest that kneeling by
patients who are overweight may reduce polyethylene life-
span (presumably because of the increased tibiofemoral
contact pressure caused by excess body mass) but no studies
have evaluated the association of body mass on kneeling
after TKA.32
Time to Improvement of Kneeling after TKA
Nearly all studies reporting on kneeling after TKA show
improvement compared with preoperative function. How-
ever, the percentage of patients able to kneel after surgery
varies from 20 to 82% and is dependent on subjective
assessment of ability, as discussed below.6,8,15,20 Most
improvement occurs from 6 to 12 months after TKA,
though there seems to be continuous substantial improve-
ments in patient-reported outcomes up to 2 years after
surgery.10,15
Perceived versus Actual Ability to Kneel
Perhaps the greatest limitation to kneeling after surgery is
patients’ perceptions that they are unable to kneel.4,20,21,28
In a study of 100 TKA procedures performed in 75 patients,
32% of them perceived an inability to kneel at least 6 months
after arthroplasty, primarily because of opinions of friends
and family, online opinion, and fear of prosthetic damage.4
However, 64% of patients who underwent TKA were able to
kneel, and only 24% of patients who underwent TKA were
unable to kneel because of problems associated with the
TKA, including pain.4 Long history of anterior knee pain as a
cause of kneeling avoidance is further supported by Hassa-
Patients’ Ability to Kneel after TKA Amin et al.
balla et al (2004),20 who showed that patients who under-
went patellofemoral arthroplasty kneel less often than
patients who underwent unicompartmental knee arthro-
plasty (UKA) despite similarly low surgical invasiveness
compared with TKA.
Another study evaluated the opinions of 70 patients who
had undergone 100 TKA procedures regarding their ability to
kneel.28 In contrast to the aforementioned study, 73% of
patients who underwent TKA believed they had the capacity
to kneel, whereas only 15% perceived a complete inability to
do so. According to physical examination findings in this
study, only 4% of patients had a continued inability to kneel
after surgery. However, 50% of patients continued to be
hesitant to kneel throughout the study and reported fear
of prosthesis damage, spinal disorders, or uncertain guidance
as the reasons.
Finally, a study of 122 patients who had undergone TKA
found that nearly 63% of reported an inability to kneel.20
However, objective findings indicated that approximately
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81% of patients were able to kneel with the assistance of a
chair and 73% were able to perform upright kneeling. Nota-
bly, the range of motion in patients with the ability to kneel
was substantially better compared with those unable to
kneel. Additionally, a greater proportion of men were able
to kneel to 90 degrees, compared with 54% of women. There
were no differences with respect to age and the ability to
kneel.
Though the rates of perceived and objective ability to
kneel differ among the studies, all studies show that a
substantial proportion of patients report an inability to
kneel despite their actual ability to do so. The barriers to
comfortable kneeling after surgery are multimodal; 58% of
patients who were categorized as having a low level of pain
by the Western Ontario and McMaster Universities
Osteoarthritis Index criteria (0–25 points) reported “severe
or extreme” difficulty in kneeling.22 Additionally, preo-
perative patient education about kneeling after TKA has
not resulted in substantial improvement in the proportion
of patients who report kneeling ability after TKA.24 There-
fore, patient perceptions of which activities are acceptable
after TKA should be assessed to allow for maximal surgical
benefit.
TKA Incisions and Kneeling
There are minimal data regarding the location of the TKA
incision and its association with kneeling ability. One study
of 22 patients with 12 midline and 10 lateral skin incisions
used the Kneeling Ability Test and the Forgotten Joint Score
to determine associations between incision location and
kneeling ability.16 The authors reported that patients with
lateral incisions had a significantly higher mean Forgotten
Joint Score (100) compared with those with midline incisions
(89.1; p ¼ 0.0098). Additionally, the group with lateral inci-
sions had a significantly higher mean Kneeling Ability Test
score at 110 degrees of flexion (98.4) compared with patients
with midline incisions (56.7) at a mean 28 months after
surgery (p ¼ 0.020).16 However, there was no difference in
The Journal of Knee Surgery
Patients’ Ability to Kneel after TKA Amin et al.
Kneeling Ability Test scores at 90 degrees of flexion between
the 2 groups, and confounding variables, including activity
level and occupation, were not considered. Additionally, the
small sample limits interpretation of these results.
Incisional numbness, caused by infrapatellar damage to
the saphenous nerve, is a known risk of midline and medial
skin incisions.38 Recent data have shown that greater area of
incisional sensory alteration after TKA is negatively asso-
ciated with kneeling ability.19 However, other data show
that circumpatellar denervation in the setting of both
resurfaced and nonresurfaced patellae does not alter kneel-
ing outcomes.12 Lateral incisions are associated with lower
risk of damage to the infrapatellar branch of the saphenous
nerve (30%) compared with midline incisions (47%) and
medial parapatellar incisions (53%), but there are insuffi-
cient data to support neural preservation through lateral
skin incision to improve kneeling ability.38,39 Additionally,
lateral incisions are contraindicated in patients with fixed
varus deformity.40
Cruciate-retaining versus Posterior-
stabilized TKA Implants
Optimal component design is controversial as it relates to
various postoperative outcomes, including kneeling. Reten-
tion of the posterior cruciate ligament is associated with
increased tibiofemoral contact pressure when moving from
double-stance to single-stance kneeling compared with
native knees.3 Additionally, kneeling with a cruciate-retain-
ing implant involves greater tibiofemoral contact area but no
difference in contact pressure compared with a posterior-
stabilized implant.3
Zhang et al39 compared various functional outcomes of
patients with high-flexion cruciate-retaining versus poster-
ior-stabilized implants. At 1-year follow-up, there was no
difference in functional outcomes, including kneeling,
between the two implant types. Though their study was
limited by short follow-up, 5-year outcomes were published
by Kolisek et al40 who also found no difference in kneeling
ability between the two implant types.
Although research suggests that kneeling outcomes are
not affected by prosthetic type, there is insufficient evidence
to make formal recommendations. Rather, surgeons’ prefer-
ence and training should dictate prosthesis type.
Mobile-Bearing versus Fixed-Bearing
Implants
Few studies show superiority in functional outcomes of
either mobile-bearing or fixed-bearing implants. Meta-
analyses have found that clinical and radiographic out-
comes and complications are similar between the two
implant types, though some data suggest that Knee Society
scores are better in patients with fixed-bearing
implants.9,11 Only one study has evaluated kneeling as a
primary outcome when considering bearing type.15 Artz
et al15 reviewed Oxford knee scores of 471 patients who
underwent UKA and 206 patients who underwent TKA. In
The Journal of Knee Surgery
the UKA group, they found no differences in ability to kneel
at 1 or 2 years after surgery by bearing type. However, in
the TKA group, their data indicated that despite similar
range of motion and Western Ontario and McMaster Uni-
versities Osteoarthritis Index scores, a significantly greater
percentage of patients in the fixed-bearing group reported
the ability to kneel.15
Patellar Resurfacing versus Nonresurfacing
Patellar resurfacing is a topic of continued debate in knee
arthroplasty because empirical evidence shows equivocal
outcomes compared with nonresurfacing. Advantages of
patellar resurfacing include a lower reoperation rate because
of less knee pain after surgery and better 2-year postopera-
tive Knee Society clinical scores41–43; however, disadvan-
tages include fracture, hardware failure, and revision
difficulty.44 Spencer et al12 retrospectively compared the
outcomes of 169 TKA procedures in 110 patients with
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circumferential patellar denervation (83 TKA) versus patellar
resurfacing (86 TKA). At a minimum of 2 years of follow-up,
they found no difference in overall functional outcomes
between the two groups, and both groups had nearly iden-
tical Clinical Knee Rating System kneeling scores (2.7 resur-
facing vs. 2.6 denervation).
Conclusion
Prosthetic type, surgical approach, and patellar resurfacing
remain controversial with respect to their effects on kneeling
after TKA. However, the difference in patients’ perceived
versus actual ability to kneel has been well documented.
Biomechanical data suggest that maximizing range of
motion enhances kneeling after surgery and should be
encouraged during the postoperative period. There is no
convincing evidence that kneeling harms knee prostheses,
and we advocate encouragement of kneeling after TKA.
Level-1 clinical studies measuring kneeling as a primary
outcome after TKA are required to substantiate these
conclusions.
Funding
None.
Conflict of Interest
None.
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