J Knee Surg 2016; 29(03): 201-217
DOI: 10.1055/s-0036-1579670
Special Focus Section
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Rehabilitative Guidelines after Total Knee Arthroplasty: A Review

Jaydev B. Mistry
1   Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
,
Randa D. K. Elmallah
1   Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
,
Anil Bhave
1   Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
,
Morad Chughtai
1   Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
,
Jeffrey Jai Cherian
2   Department of Orthopaedics, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
,
Tanner McGinn
1   Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
,
Steven F. Harwin
3   Department of Orthopaedic Surgery, Beth Israel Medical Center, New York, New York
,
Michael A. Mont
1   Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopaedics, Baltimore, Maryland
› Author Affiliations
Further Information

Publication History

13 October 2015

31 January 2016

Publication Date:
10 March 2016 (online)

Abstract

Rehabilitation following total knee arthroplasty (TKA) continues to pose a challenge for both patients and providers. In addition, guidelines vary considerably between institutions, which often leave therapy regimens to the discretion of the provider. The lack of clear guidelines for rehabilitation may contribute to inadequate recovery of strength and range-of-motion, resulting in less optimal functional outcomes. Therefore, the aim of this review was to highlight and discuss a variety of post-TKA rehabilitative modalities currently available and to provide evidence regarding efficacy and practicality. Specifically, we assessed the role of and evidence for exercise therapy, aquatic therapy, balance training, continuous passive motion, cold therapy and compression, neuromuscular electrical stimulation, transcutaneous electrical nerve stimulation, and instrument-assisted soft-tissue therapy. Additionally, we proposed general recommendations for rehabilitation after TKA, and as we specifically described active and obese patients, we have included guidelines for these subsets as well. Our review examines the various rehabilitative modalities to offer suggestions for recovery of strength and range-of-motion after TKA, with a focus on the early incorporation of exercise therapy, balance training, aquatic therapy, cryopneumatic therapy, neuromuscular electrical stimulation, and transcutaneous electrical nerve stimulation. Dedication and commitment to rehabilitation may help patients attain and exceed their preoperative activity levels.

 
  • References

  • 1 Kurtz SM, Ong KL, Schmier J , et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am 2007; 89 (Suppl. 03) 144-151
  • 2 Bade MJ, Kohrt WM, Stevens-Lapsley JE. Outcomes before and after total knee arthroplasty compared to healthy adults. J Orthop Sports Phys Ther 2010; 40 (9) 559-567
  • 3 Barrack RL, Ruh EL, Chen J , et al. Impact of socioeconomic factors on outcome of total knee arthroplasty. Clin Orthop Relat Res 2014; 472 (1) 86-97
  • 4 Ibrahim MS, Alazzawi S, Nizam I, Haddad FS. An evidence-based review of enhanced recovery interventions in knee replacement surgery. Ann R Coll Surg Engl 2013; 95 (6) 386-389
  • 5 Rubin LE, Murgo KT. Brief report: total knee arthroplasty performed with patient-specific, pre-operative CT-guided navigation. R I Med J (2013) 2013; 96 (3) 34-37
  • 6 Stiehl JB, Heck DA. How precise is computer-navigated gap assessment in TKA?. Clin Orthop Relat Res 2015; 473 (1) 115-118
  • 7 Banerjee S, Cherian JJ, Elmallah RK, Jauregui JJ, Pierce TP, Mont MA. Robotic-assisted knee arthroplasty. Expert Rev Med Devices 2015; 12 (6) 727-735
  • 8 Mizner RL, Petterson SC, Stevens JE, Vandenborne 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 (5) 1047-1053
  • 9 Bjerke J, Öhberg F, Nilsson KG, Stensdotter AK. Compensatory strategies for muscle weakness during stair ascent in subjects with total knee arthroplasty. J Arthroplasty 2014; 29 (7) 1499-1502
  • 10 Doerfler D, Gurney B, Mermier C, Rauh M, Black L, Andrews R. High-velocity quadriceps exercises compared to slow-velocity quadriceps exercises following total knee arthroplasty: a randomized clinical study. J Geriatr Phys Ther 2015; ; doi: 10.1519/JPT.0000000000000071
  • 11 Thomas AC, Judd DL, Davidson BS, Eckhoff DG, Stevens-Lapsley JE. Quadriceps/hamstrings co-activation increases early after total knee arthroplasty. Knee 2014; 21 (6) 1115-1119
  • 12 Yoshida Y, Mizner RL, Snyder-Mackler L. Association between long-term quadriceps weakness and early walking muscle co-contraction after total knee arthroplasty. Knee 2013; 20 (6) 426-431
  • 13 Stevens-Lapsley JE, Balter JE, Kohrt WM, Eckhoff DG. Quadriceps and hamstrings muscle dysfunction after total knee arthroplasty. Clin Orthop Relat Res 2010; 468 (9) 2460-2468
  • 14 Ardali G. A daily adjustable progressive resistance exercise protocol and functional training to increase quadriceps muscle strength and functional performance in an elderly homebound patient following a total knee arthroplasty. Physiother Theory Pract 2014; 30 (4) 287-297
  • 15 Meier W, Mizner RL, Marcus RL, Dibble LE, Peters C, Lastayo PC. Total knee arthroplasty: muscle impairments, functional limitations, and recommended rehabilitation approaches. J Orthop Sports Phys Ther 2008; 38 (5) 246-256
  • 16 Brander VA, Stulberg SD, Chang RW. Life after total hip arthroplasty. Bull Rheum Dis 1993; 42 (3) 1-5
  • 17 Taniguchi M, Sawano S, Kugo M, Maegawa S, Kawasaki T, Ichihashi N. Physical activity promotes gait improvement in patients with total knee arthroplasty. J Arthroplasty 2015; (e-pub ahead of print). doi: 10.1016/j.arth.2015.11.012
  • 18 Peter WF, Nelissen RG, Vlieland TP. Guideline recommendations for post-acute postoperative physiotherapy in total hip and knee arthroplasty: are they used in daily clinical practice?. Musculoskelet Care 2014; 12 (3) 125-131
  • 19 Brander V, Stulberg SD. Rehabilitation after hip- and knee-joint replacement. An experience- and evidence-based approach to care. Am J Phys Med Rehabil 2006; 85 (11, Suppl): S98-S118 , quiz S119–S123
  • 20 Bade MJ, Stevens-Lapsley JE. Restoration of physical function in patients following total knee arthroplasty: an update on rehabilitation practices. Curr Opin Rheumatol 2012; 24 (2) 208-214
  • 21 Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med 2013; 49 (6) 877-892
  • 22 Westby MD, Brittain A, Backman CL. Expert consensus on best practices for post-acute rehabilitation after total hip and knee arthroplasty: a Canada and United States Delphi study. Arthritis Care Res (Hoboken) 2014; 66 (3) 411-423
  • 23 Bade MJ, Stevens-Lapsley JE. Early high-intensity rehabilitation following total knee arthroplasty improves outcomes. J Orthop Sports Phys Ther 2011; 41 (12) 932-941
  • 24 Kolisek FR, Gilmore KJ, Peterson EK. Slide and flex, tighten, extend (SAFTE): a safe, convenient, effective, and no-cost approach to rehabilitation after total knee arthroplasty. J Arthroplasty 2000; 15 (8) 1013-1016
  • 25 Petterson SC, Mizner RL, Stevens JE , et al. Improved function from progressive strengthening interventions after total knee arthroplasty: a randomized clinical trial with an imbedded prospective cohort. Arthritis Rheum 2009; 61 (2) 174-183
  • 26 Moffet H, Collet JP, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: A single-blind randomized controlled trial. Arch Phys Med Rehabil 2004; 85 (4) 546-556
  • 27 Evgeniadis G, Beneka A, Malliou P , et al. Effects of pre- or postoperative therapeutic exercise on the quality of life, before and after total knee arthroplasty for osteoarthritis. J Back Musculoskeletal Rehabil 2008; 21: 161-169
  • 28 Devers BN, Conditt MA, Jamieson ML, Driscoll MD, Noble PC, Parsley BS. Does greater knee flexion increase patient function and satisfaction after total knee arthroplasty?. J Arthroplasty 2011; 26 (2) 178-186
  • 29 Rowe PJ, Myles CM, Walker C, Nutton R. Knee joint kinematics in gait and other functional activities measured using flexible electrogoniometry: how much knee motion is sufficient for normal daily life?. Gait Posture 2000; 12 (2) 143-155
  • 30 Tew M, Forster IW, Wallace WA. Effect of total knee arthroplasty on maximal flexion. Clin Orthop Relat Res 1989; (247) 168-174
  • 31 Kim J, Nelson CL, Lotke PA. Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision. J Bone Joint Surg Am 2004; 86-A (7) 1479-1484
  • 32 Maloney WJ. The stiff total knee arthroplasty: evaluation and management. J Arthroplasty 2002; 17 (4) (Suppl. 01) 71-73
  • 33 McGrath MS, Mont MA, Siddiqui JA, Baker E, Bhave A. Evaluation of a custom device for the treatment of flexion contractures after total knee arthroplasty. Clin Orthop Relat Res 2009; 467 (6) 1485-1492
  • 34 Tanzer M, Miller J. The natural history of flexion contracture in total knee arthroplasty. A prospective study. Clin Orthop Relat Res 1989; (248) 129-134
  • 35 Shoji H, Solomonow M, Yoshino S, D'Ambrosia R, Dabezies E. Factors affecting postoperative flexion in total knee arthroplasty. Orthopedics 1990; 13 (6) 643-649
  • 36 McPherson EJ, Cushner FD, Schiff CF, Friedman RJ. Natural history of uncorrected flexion contractures following total knee arthroplasty. J Arthroplasty 1994; 9 (5) 499-502
  • 37 Lizaur A, Marco L, Cebrian R. Preoperative factors influencing the range of movement after total knee arthroplasty for severe osteoarthritis. J Bone Joint Surg Br 1997; 79 (4) 626-629
  • 38 Cheng K, Dashti H, McLeod G. Does flexion contracture continue to improve up to five years after total knee arthroplasty?. J Orthop Surg (Hong Kong) 2007; 15 (3) 303-305
  • 39 Bonutti PM, Marulanda GA, McGrath MS, Mont MA, Zywiel MG. Static progressive stretch improves range of motion in arthrofibrosis following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2010; 18 (2) 194-199
  • 40 Valtonen A, Pöyhönen T, Sipilä S, Heinonen A. Effects of aquatic resistance training on mobility limitation and lower-limb impairments after knee replacement. Arch Phys Med Rehabil 2010; 91 (6) 833-839
  • 41 Pöyhönen T, Sipilä S, Keskinen KL, Hautala A, Savolainen J, Mälkiä E. Effects of aquatic resistance training on neuromuscular performance in healthy women. Med Sci Sports Exerc 2002; 34 (12) 2103-2109
  • 42 Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial. Arch Phys Med Rehabil 2009; 90 (5) 745-755
  • 43 Valtonen A, Pöyhönen T, Sipilä S, Heinonen A. Maintenance of aquatic training-induced benefits on mobility and lower-extremity muscles among persons with unilateral knee replacement. Arch Phys Med Rehabil 2011; 92 (12) 1944-1950
  • 44 Harmer AR, Naylor JM, Crosbie J, Russell T. Land-based versus water-based rehabilitation following total knee replacement: a randomized, single-blind trial. Arthritis Rheum 2009; 61 (2) 184-191
  • 45 Piva SR, Gil AB, Almeida GJ, DiGioia III AM, Levison TJ, Fitzgerald GK. A balance exercise program appears to improve function for patients with total knee arthroplasty: a randomized clinical trial. Phys Ther 2010; 90 (6) 880-894
  • 46 Mouchnino L, Gueguen N, Blanchard C , et al. Sensori-motor adaptation to knee osteoarthritis during stepping-down before and after total knee replacement. BMC Musculoskelet Disord 2005; 6: 21
  • 47 Solomonow M, Krogsgaard M. Sensorimotor control of knee stability. A review. Scand J Med Sci Sports 2001; 11 (2) 64-80
  • 48 Fitzgerald GK, Childs JD, Ridge TM, Irrgang JJ. Agility and perturbation training for a physically active individual with knee osteoarthritis. Phys Ther 2002; 82 (4) 372-382
  • 49 Gstoettner M, Raschner C, Dirnberger E, Leimser H, Krismer M. Preoperative proprioceptive training in patients with total knee arthroplasty. Knee 2011; 18 (4) 265-270
  • 50 Liao CD, Liou TH, Huang YY, Huang YC. Effects of balance training on functional outcome after total knee replacement in patients with knee osteoarthritis: a randomized controlled trial. Clin Rehabil 2013; 27 (8) 697-709
  • 51 Fung V, Ho A, Shaffer J, Chung E, Gomez M. Use of Nintendo Wii Fit™ in the rehabilitation of outpatients following total knee replacement: a preliminary randomised controlled trial. Physiotherapy 2012; 98 (3) 183-188
  • 52 Ritter MA, Gandolf VS, Holston KS. Continuous passive motion versus physical therapy in total knee arthroplasty. Clin Orthop Relat Res 1989; (244) 239-243
  • 53 Ritter MA, Stringer EA. Predictive range of motion after total knee replacement. Clin Orthop Relat Res 1979; (143) 115-119
  • 54 Romness DW, Rand JA. The role of continuous passive motion following total knee arthroplasty. Clin Orthop Relat Res 1988; (226) 34-37
  • 55 Mau-Moeller A, Behrens M, Finze S, Bruhn S, Bader R, Mittelmeier W. The effect of continuous passive motion and sling exercise training on clinical and functional outcomes following total knee arthroplasty: a randomized active-controlled clinical study. Health Qual Life Outcomes 2014; 12: 68
  • 56 McInnes J, Larson MG, Daltroy LH , et al. A controlled evaluation of continuous passive motion in patients undergoing total knee arthroplasty. JAMA 1992; 268 (11) 1423-1428
  • 57 Pope RO, Corcoran S, McCaul K, Howie DW. Continuous passive motion after primary total knee arthroplasty. Does it offer any benefits?. J Bone Joint Surg Br 1997; 79 (6) 914-917
  • 58 Maniar RN, Baviskar JV, Singhi T, Rathi SS. To use or not to use continuous passive motion post-total knee arthroplasty presenting functional assessment results in early recovery. J Arthroplasty 2012; 27 (2) 193-200.e1
  • 59 Joshi RN, White PB, Murray-Weir M, Alexiades MM, Sculco TP, Ranawat AS. Prospective Randomized Trial of the Efficacy of Continuous Passive Motion Post Total Knee Arthroplasty: Experience of the Hospital for Special Surgery. J Arthroplasty 2015; 30 (12) 2364-2369
  • 60 Levy AS, Marmar E. The role of cold compression dressings in the postoperative treatment of total knee arthroplasty. Clin Orthop Relat Res 1993; (297) 174-178
  • 61 Abramson DI, Chu LS, Tuck Jr S, Lee SW, Richardson G, Levin M. Effect of tissue temperatures and blood flow on motor nerve conduction velocity. JAMA 1966; 198 (10) 1082-1088
  • 62 Stålman A, Berglund L, Dungnerc E, Arner P, Felländer-Tsai L. Temperature-sensitive release of prostaglandin E2 and diminished energy requirements in synovial tissue with postoperative cryotherapy: a prospective randomized study after knee arthroscopy. J Bone Joint Surg Am 2011; 93 (21) 1961-1968
  • 63 Su EP, Perna M, Boettner F , et al. A prospective, multi-center, randomised trial to evaluate the efficacy of a cryopneumatic device on total knee arthroplasty recovery. J Bone Joint Surg Br 2012; 94 (11, Suppl A): 153-156
  • 64 Bech M, Moorhen J, Cho M, Lavergne MR, Stothers K, Hoens AM. Device or ice: the effect of consistent cooling using a device compared with intermittent cooling using an ice bag after total knee arthroplasty. Physiother Can 2015; 67 (1) 48-55
  • 65 Sinacore DR, Delitto A, King DS, Rose SJ. Type II fiber activation with electrical stimulation: a preliminary report. Phys Ther 1990; 70 (7) 416-422
  • 66 Delitto A, Snyder-Mackler L. Two theories of muscle strength augmentation using percutaneous electrical stimulation. Phys Ther 1990; 70 (3) 158-164
  • 67 Sisk TD, Stralka SW, Deering MB, Griffin JW. Effect of electrical stimulation on quadriceps strength after reconstructive surgery of the anterior cruciate ligament. Am J Sports Med 1987; 15 (3) 215-220
  • 68 Snyder-Mackler L, Delitto A, Stralka SW, Bailey SL. Use of electrical stimulation to enhance recovery of quadriceps femoris muscle force production in patients following anterior cruciate ligament reconstruction. Phys Ther 1994; 74 (10) 901-907
  • 69 Stevens JE, Mizner RL, Snyder-Mackler L. Neuromuscular electrical stimulation for quadriceps muscle strengthening after bilateral total knee arthroplasty: a case series. J Orthop Sports Phys Ther 2004; 34 (1) 21-29
  • 70 Binder-Macleod SA, Halden EE, Jungles KA. Effects of stimulation intensity on the physiological responses of human motor units. Med Sci Sports Exerc 1995; 27 (4) 556-565
  • 71 Cabric M, Appell HJ, Resic A. Fine structural changes in electrostimulated human skeletal muscle. Evidence for predominant effects on fast muscle fibres. Eur J Appl Physiol Occup Physiol 1988; 57 (1) 1-5
  • 72 Hainaut K, Duchateau J. Neuromuscular electrical stimulation and voluntary exercise. Sports Med 1992; 14 (2) 100-113
  • 73 Trimble MH, Enoka RM. Mechanisms underlying the training effects associated with neuromuscular electrical stimulation. Phys Ther 1991; 71 (4) 273-280 , discussion 280–282
  • 74 Kent-Braun JA, Le Blanc R. Quantitation of central activation failure during maximal voluntary contractions in humans. Muscle Nerve 1996; 19 (7) 861-869
  • 75 Wolfson L, Judge J, Whipple R, King M. Strength is a major factor in balance, gait, and the occurrence of falls. J Gerontol A Biol Sci Med Sci 1995; 50 (Spec No): 64-67
  • 76 Chandler JM, Duncan PW, Kochersberger G, Studenski S. Is lower extremity strength gain associated with improvement in physical performance and disability in frail, community-dwelling elders?. Arch Phys Med Rehabil 1998; 79 (1) 24-30
  • 77 Rantanen T, Guralnik JM, Izmirlian G , et al. Association of muscle strength with maximum walking speed in disabled older women. Am J Phys Med Rehabil 1998; 77 (4) 299-305
  • 78 Fahrer H, Rentsch HU, Gerber NJ, Beyeler C, Hess CW, Grünig B. Knee effusion and reflex inhibition of the quadriceps. A bar to effective retraining. J Bone Joint Surg Br 1988; 70 (4) 635-638
  • 79 Stevens-Lapsley JE, Balter JE, Wolfe P, Eckhoff DG, Kohrt WM. Early neuromuscular electrical stimulation to improve quadriceps muscle strength after total knee arthroplasty: a randomized controlled trial. Phys Ther 2012; 92 (2) 210-226
  • 80 Avramidis K, Karachalios T, Popotonasios K, Sacorafas D, Papathanasiades AA, Malizos KN. Does electric stimulation of the vastus medialis muscle influence rehabilitation after total knee replacement?. Orthopedics 2011; 34 (3) 175
  • 81 Levine M, McElroy K, Stakich V, Cicco J. Comparing conventional physical therapy rehabilitation with neuromuscular electrical stimulation after TKA. Orthopedics 2013; 36 (3) e319-e324
  • 82 Rakel BA, Zimmerman MB, Geasland K , et al. Transcutaneous electrical nerve stimulation for the control of pain during rehabilitation after total knee arthroplasty: A randomized, blinded, placebo-controlled trial. Pain 2014; 155 (12) 2599-2611
  • 83 DeSantana JM, Walsh DM, Vance C, Rakel BA, Sluka KA. Effectiveness of transcutaneous electrical nerve stimulation for treatment of hyperalgesia and pain. Curr Rheumatol Rep 2008; 10 (6) 492-499
  • 84 DeLoach LJ, Higgins MS, Caplan AB, Stiff JL. The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale. Anesth Analg 1998; 86 (1) 102-106
  • 85 Kalra A, Urban MO, Sluka KA. Blockade of opioid receptors in rostral ventral medulla prevents antihyperalgesia produced by transcutaneous electrical nerve stimulation (TENS). J Pharmacol Exp Ther 2001; 298 (1) 257-263
  • 86 Ma YT, Sluka KA. Reduction in inflammation-induced sensitization of dorsal horn neurons by transcutaneous electrical nerve stimulation in anesthetized rats. Exp Brain Res 2001; 137 (1) 94-102
  • 87 Sluka KA, Deacon M, Stibal A, Strissel S, Terpstra A. Spinal blockade of opioid receptors prevents the analgesia produced by TENS in arthritic rats. J Pharmacol Exp Ther 1999; 289 (2) 840-846
  • 88 Stabile ML, Mallory TH. The management of postoperative pain in total joint replacement: transcutaneous electrical nerve stimulation is evaluated in total hip and knee patients. Orthop Rev 1978; 7: 121-123
  • 89 Breit R, Van der Wall H. Transcutaneous electrical nerve stimulation for postoperative pain relief after total knee arthroplasty. J Arthroplasty 2004; 19 (1) 45-48
  • 90 Angulo DL, Colwell CW. Use of Postoperative TENS and Continuous Passive Motion Following Total Knee Replacement. J Orthop Sports Phys Ther 1990; 11 (12) 599-604
  • 91 Hing WBR, Bremner T. Mulligan's mobilization with movement: A systematic Review. J Manual Manip Ther 2009; 17: 25
  • 92 Sevier TL, Stegink-Jansen CW. Astym treatment vs. eccentric exercise for lateral elbow tendinopathy: a randomized controlled clinical trial. PeerJ 2015; 3: e967
  • 93 Slaven EJ, Mathers J. Management of chronic ankle pain using joint mobilization and ASTYM® treatment: a case report. J Manual Manip Ther 2011; 19 (2) 108-112
  • 94 Davidson CJ, Ganion LR, Gehlsen GM, Verhoestra B, Roepke JE, Sevier TL. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med Sci Sports Exerc 1997; 29 (3) 313-319
  • 95 Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization pressure. Med Sci Sports Exerc 1999; 31 (4) 531-535
  • 96 Cerny K, Perry J, Walker JM. Adaptations during the stance phase of gait for simulated flexion contractures at the knee. Orthopedics 1994; 17 (6) 501-512 , discussion 512–513
  • 97 Ritter MA, Lutgring JD, Davis KE, Berend ME, Pierson JL, Meneghini RM. The role of flexion contracture on outcomes in primary total knee arthroplasty. J Arthroplasty 2007; 22 (8) 1092-1096
  • 98 McCormack JR. The management of bilateral high hamstring tendinopathy with ASTYM® treatment and eccentric exercise: a case report. J Manual Manip Ther 2012; 20 (3) 142-146
  • 99 McCormack JR. The management of mid-portion achilles tendinopathy with astym® and eccentric exercise: a case report. Int J Sports Phys Ther 2012; 7 (6) 672-677
  • 100 Tyler A, Slaven E. The role of the Astym (R) process in the management of osteoarthritis of the knee: a single-subject research design. J Stud Phys Ther Res 2013; 6: 10
  • 101 Böstman OM. Prevalence of obesity among patients admitted for elective orthopaedic surgery. Int J Obes Relat Metab Disord 1994; 18 (10) 709-713
  • 102 Järvenpää J, Kettunen J, Kröger H, Miettinen H. Obesity may impair the early outcome of total knee arthroplasty. Scand J Surg 2010; 99 (1) 45-49
  • 103 Miric A, Lim M, Kahn B, Rozenthal T, Bombick D, Sculco TP. Perioperative morbidity following total knee arthroplasty among obese patients. J Knee Surg 2002; 15 (2) 77-83
  • 104 Samson AJ, Mercer GE, Campbell DG. Total knee replacement in the morbidly obese: a literature review. ANZ J Surg 2010; 80 (9) 595-599
  • 105 Amin AK, Clayton RA, Patton JT, Gaston M, Cook RE, Brenkel IJ. Total knee replacement in morbidly obese patients. Results of a prospective, matched study. J Bone Joint Surg Br 2006; 88 (10) 1321-1326
  • 106 Hamoui N, Kantor S, Vince K, Crookes PF. Long-term outcome of total knee replacement: does obesity matter?. Obes Surg 2006; 16 (1) 35-38
  • 107 Odum SM, Springer BD, Dennos AC, Fehring TK. National obesity trends in total knee arthroplasty. J Arthroplasty 2013; 28 (8, Suppl) 148-151
  • 108 Gillespie GN, Porteous AJ. Obesity and knee arthroplasty. Knee 2007; 14 (2) 81-86
  • 109 Healy WL, Iorio R, Lemos MJ. Athletic activity after total knee arthroplasty. Clin Orthop Relat Res 2000; (380) 65-71
  • 110 Kuster MS. Exercise recommendations after total joint replacement: a review of the current literature and proposal of scientifically based guidelines. Sports Med 2002; 32 (7) 433-445
  • 111 Seyler TM, Mont MA, Ragland PS, Kachwala MM, Delanois RE. Sports activity after total hip and knee arthroplasty : specific recommendations concerning tennis. Sports Med 2006; 36 (7) 571-583
  • 112 Maloney WJ, Galante JO, Anderson M , et al. Fixation, polyethylene wear, and pelvic osteolysis in primary total hip replacement. Clin Orthop Relat Res 1999; (369) 157-164
  • 113 Harris WH. Wear and periprosthetic osteolysis: the problem. Clin Orthop Relat Res 2001; (393) 66-70
  • 114 Jones DL, Cauley JA, Kriska AM , et al. Physical activity and risk of revision total knee arthroplasty in individuals with knee osteoarthritis: a matched case-control study. J Rheumatol 2004; 31 (7) 1384-1390
  • 115 Mont MA, Mathur SK, Krackow KA, Loewy JW, Hungerford DS. Cementless total knee arthroplasty in obese patients. A comparison with a matched control group. J Arthroplasty 1996; 11 (2) 153-156
  • 116 Lavernia CJ, Sierra RJ, Hungerford DS, Krackow K. Activity level and wear in total knee arthroplasty: a study of autopsy retrieved specimens. J Arthroplasty 2001; 16 (4) 446-453
  • 117 Mintz L, Tsao AK, McCrae CR, Stulberg SD, Wright T. The arthroscopic evaluation and characteristics of severe polyethylene wear in total knee arthroplasty. Clin Orthop Relat Res 1991; (273) 215-222
  • 118 Swiss Federal Office of Sports. Economic benefits of the health-enhancing effects of physical activity: first estimates for Switzerland: scientific position statement. Schweizerische Zeitschrift fur Sportmedizin und Sporttraumatologie 2001;
  • 119 Ebert JR, Munsie C, Joss B. Guidelines for the early restoration of active knee flexion after total knee arthroplasty: implications for rehabilitation and early intervention. Arch Phys Med Rehabil 2014; 95 (6) 1135-1140