ARTICLES

• The Knee Society: Total Knee Replacement—Recommended and Discouraged Activities
• American Academy of Orthopedic Surgeons: Knee Replacement Exercise Guide

  A comprehensive assortment of early post-op knee replacement exercises including illustrations

• Exercise Net: Knee Articulations

  Knee muscle anatomy described and illustrated with still pictures and videos

• “Stresses on Your New Knee Joint”

  An illustrated overview from Total Joints—a noncommercial site posting from Sweden, in English translation, as a public service to patients:

  “… In a total knee prosthesis, the stresses are concentrated on smaller areas than in normal knees…What matters is the stress on the polyethylene [PE] surface of the tibial component…PE has only limited resistance against high stresses. If the stresses exceed a limit, the PE will be damaged.”

• Noble PC et al.: Clin Orthop Relat Res. 2005; Feb(431): 157-65 “Does total knee replacement restore normal knee function?”

  Authors’ conclusions: “Our data show that many of the limitations reported by patients after total knee arthroplasties are shared by individuals with no previous knee disorders. However, only approximately 40% of the functional deficit present after a total knee arthroplasty seems to be attributable to the normal physiologic effects of aging. Patients who had total knee replacements still experienced substantial functional impairment compared with their age- and gender-matched peers, especially when doing biomechanically demanding activities. This suggests that significant improvements in the procedure and prosthetic designs are needed to restore normal knee function after a total knee arthroplasty.”

• Kuster MS et al.: Am J Sports Med. 2002; 32(7): 433-45 “Exercise recommendations after total joint replacement: a review of the current literature and proposal of scientifically based guidelines”

  Summary: The author of this review study recommends that TKA patients remain active but stick to “low joint load” activities for routine physical fitness, such as swimming, cycling, and “possibly” power walking (on flat ground). Skilled hikers and skiers can participate in those sports occasionally, for fun, but patients should avoid unfamiliar sports after joint replacement. TKA patients also should avoid activities that place a high load on the knee when it is bent at 40-60 degrees (such as in hill hiking), because it places high stress on the polyethylene component.

• McGrory BJ et al.: Mayo Clin Proc. 1995 Apr;70(4):342-8 “Participation in sports after hip and knee arthroplasty: review of literature and survey of surgeon preferences”

  Summary: The authors searched the scientific literature on the topic and surveyed 28 orthopedic surgeons—about half of them young residents and “fellows” and half staff consultants—at the Mayo Clinic. For an activity to be designated as either “recommended” or “not recommended,” 75% of surgeons had to agree. Young surgeons were more cautious than staff surgeons about allowing a return to cross-country skiing. Otherwise, survey responses were similar: “Recommended sports included sailing, swimming laps, scuba diving, cycling, golfing, and bowling after hip and knee replacement procedures and also cross-country skiing after knee arthroplasty. Sports not recommended after hip or knee arthroplasty were running, waterskiing, football, baseball, basketball, hockey, handball, karate, soccer, and racquetball. ”

  Note: Recommendations about sports after TKA differ slightly with respect to specific activities, but consensus exists in favor of low-impact activities that avoid twisting the knee.

BOOKS

“Exercise beats arthritis” by Valerie Sayce et al

“Healing Hip, Joint and Knee Pain” by Kate S. O’Shea

“The Complete Waterpower Workout Book” by Linda Huey, et al

“The Egoscue Method of Health Through Motion: Revolutionary Program That Lets You Rediscover the Body’s Power to Rejuvenate It” by Pete Egoscue

GOLF

Rothman Institute “Playing Golf and Knee Replacement Surgery”

The seven tips in this short article explain how to resume golfing in a way that avoids overloading or twisting an artificial knee.

1. Start slowly with chipping and putting before progressing to playing 9 or 18 holes.
2. While walking exercise is important for your heart, resume your golfing career by using a cart. Eventually you can walk the course. At that time use a caddy or a roller for your bag. Carrying your bag increases forces across your knee joint and may excessively stress your new knee.
3. Use spikeless shoes. Spiked shoes fix your stance during the golf swing and will increase rotational stress on your artificial knee. As most courses now require spikeless shoes, this advice may be superfluous.
4. Avoid playing in wet weather where the chance of slipping or falling during a golf swing is increased.
5. Learn to play more “on the toes”. Swinging flat-footed increases stresses on the joint replacement. On the backswing, the left heel should come off the ground and on the downswing, the right heel should come off the ground. (Note- This recommendation is for right-handed golfers and the terms “right/left” need to be reversed for left-handed golfers. This advisory was added by Dr. Hozack who plays as a lefty.)
6. Right-handed golfers with a right total knee replacement may benefit from “stepping through” their swing with their right leg. The right leg comes off the ground during the downswing and follow-through, and actually steps toward the target. This will effectively unload a right total knee replacement; however, no golfer with a left total knee replacement should attempt this, as it may result in excessive loading of the left knee.
7. Right-handed golfers with a left total knee replacement may benefit from an open stance. This may make the backswing a little more difficult, but if the player allows his left heel to come up, he should still be able to accomplish a full turn. The open stance has the golfer facing the target, and the hips do not need to turn as drastically to the left in the impact zone, thereby reducing the stress and torque within the left knee.

HORSEBACK RIDING

The Knee Society lists it as “slightly more risky,” and “Exercise Recommendations after Total Joint Replacement” advises avoiding repeated full loading of the knee (with all your weight on it) in 40-60 degrees of flexion.

TENNIS

Mont MA et al.: Am J Sports Med 2002; 30:163-166 “Tennis after Total Knee Arthroplasty”

Summary: A questionnaire was sent to United States Tennis Association members who had undergone a total knee arthroplasty (TKA). The study group included 28 men and 5 women (46 knees) with a mean age of 64 years. Only 21% of the patients’ surgeons approved of them playing tennis, and 45% of surgeons recommended only doubles. All patients were satisfied with their TKAs and tended to play at a high level—about three times per week, which does not reflect the level in the general population. Future studies should try to determine the effect of tennis on the general population of patients with knee arthroplasty, particularly the effect after 15-20 years. Until such studies are performed, the authors recommend that physicians advise caution in tennis after TKA.

EXERCISE EQUIPMENT

• Walkaerobics.com In-home walking video
• Kangoojumps.com Low impact rebound shoes
• Study of Impact Shock during Jogging

SPORTS MEDICINE

The American Journal of Sports Medicine

American Physical Therapy Association