Case Study TKR

Aimi Nabilah binti Sukor (1515950) Clinical Physiotherapy II (AHP3126)
DEPARTMENT OF PHYSICAL REHABILITATION SCIENCES
RIGHT TOTAL KNEE REPLACEMENT
CLINILCAL POSTING II AHP3126
NAME: AIMI NABILAH BINTI SUKOR
MATRIC NO: 1515950
PROGRAM: BACHELOR OF PHYSIOTHERAPY
LEVEL: 4TH YEAR SEMESTER 1
1
INTRODUCTION
Knee joint is the largest and the most complex joint in the body. Knee is a type of modified
hinge joint, because it’s primary movement in uniaxial hinge movement. Furthermore knee
joint consist of three joint within the synovial cavity. Laterally, there are tibiofemoral joint,
consists of lateral condyle of the femur, lateral meniscus and lateral condyle of tibia, which is
the weigh bearing bone of the leg. Medially is another tibiofemoral joint, consist of medial
condyle of femur, medial meniscus and medial condyle of tibia. The third is, patellafemoral
joint, between the knee cap and patella surface of the femur which called intercondylar
groove (Tortorra & Derikson 2014).
In addition, according to Foran(2015) knee pain and disability commonly caused by arthritis.
Usually, there are three types of arthritis that attribute to the chronic knee pain. The most
familiar is osteoarthritis. This is an age-related "wear and tear" type of arthritis. It usually
occurs in people 50 years of age and older, but may occur in younger people, too. The
cartilage that cushions the bones of the knee softens and wears away. The bones then rub
against one another, causing knee pain and stiffness. The other typical type of arthritis is
rheumatoid arthritis. This is a disease in which the synovial membrane that surrounds the
joint becomes inflamed and thickened. This chronic inflammation can damage the cartilage
and eventually cause cartilage loss, pain, and stiffness. Rheumatoid arthritis is the most
common form of a group of disorders termed "inflammatory arthritis." However there are
external factor mainly attribute to arthritis, which is post-traumatic arthritis. This can follow a
serious knee injury. Fractures of the bones surrounding the knee or tears of the knee
ligaments may damage the articular cartilage over time, causing knee pain and limiting knee
function. Hence, the main factor of total knee replacement can be done is if the patient had
suffered chronic arthritis disorder for prolonged period.
Total knee replacement firstly done on 1968. The procedures are a surgeon removes some
bone and cartilage from the femur and tibia. The surgeon then replaces the epicondyle of
femur with a metal implant and the epicondyle of tibia with a plastic implant. In certain cases
the surgeon also replaces the posterior surface of patella with a plastic coating. There are two
types of total knee replacement surgery which are partial knee replacement and total knee
replacement. The partial knee replacement (PKR) is usually done if there are not more than
three component of the knee joint has been damaged. Commonly, the operation takes place in
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any of three anatomical compartments of the knee where diseased bone presents the most
pain: the medial compartment located on the inside of the knee, the lateral compartment on
the outside of the knee, or the patella femoral compartment. The advantage of PKR are early
discharge period, faster recovery and short rehabilitation period, less pain following surgery,
and less trauma and blood loss. However, there is less assurance that a PKR will reduce or
eliminate the underlying pain. Meanwhile, the total knee replacement is removing the
epicondyle of femur, epicondyle of tibia and posterior surface of the patella and replace with
arthrosis(Sullivan,2016).
In other hand, doing some exercises prior to total knee replacement is very crucial because it
will enhance the muscle power, improve the flexibility and faster recover. It can be done by
start with five to ten repetitions of each exercise twice a day the first week, then increase to
ten to fifth teen repetitions by week two, and finally rose to fifth teen to twenty repetitions by
week three. There are ten types of exercise can be perform which are, static quads exercise
(SQE), four plane straight leg raising (SLR), clamshell exercise, knee bending exercise,
quads bench exercise, chair push up, inner range quads (IRQ) and single leg stance exercise
with hand support (Greengard, 2016).
After the total knee replacement surgical, there are some risks. The 30-day mortality rate for
a total knee replacement (TKR) is about 1 in 400, or 0.25 percent. That means that 99.75
percent of those who undergo this surgery survive the treatment. Researchers in the U.K.
reported in The Bone & Joint Journal that they looked at almost 2,500 people who had a TKR
over a 10-year span. They found that 99 percent survived at least one year. Ninety percent
were alive after five years. Eighty-four percent were still living after 10 years. Overall,
mortality rates are highest in the 30 to 90 days following surgery. However, there is several
complication posts to total knee replacement. About 1% of people get a postoperative
infection. The same-day death rate for this same group is extremely rare (0.001 percent).
Blood clots are a risk, as they are with most orthopedic surgeries, but common preventative
measures have reduced their risk. Less than 2% of people get them now. Besides, cases of
osteolysis might occurred when plastic or metal fragments are released from the knee implant
into the body and cause inflammation but it is uncommon (Morrison, 2017).
Doctor management after the surgery is depending on the complication that patient may get.
For example, doctor will give warfarin, heparin or aspirin after the operation to avoid blood
clot. In the same time, doctor may suggest treatments like support stockings, lower leg
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exercises, calf pumps, or elevating the legs to help increase circulation and prevent clots from
forming. In order to avoid any infection, the doctor will give antibiotics before, during and
after the surgery (Morrison, 2017). While, to manage the pain, the doctor will give include
prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or
naproxen. If severe pain persists, your doctor might prescribe stronger pain relievers such as
tramadol (Ultram) or oxycodone. Swelling is common after 2 to 3 weeks after surgery and it
may last for 3 to 6 months doctor will recommend to put ice pack and elevate the leg. At
home the doctor suggest to wear compression stocking to prevent blood clots and apply
topical cream that contain active ingredients such as capsaicin, menthol, or salicylates. These
ingredients are well-known to ease pain when they’re applied on the skin (Stephens, 2017)
Patient will be refer to the physiotherapist to increase the range of motion, improve the
muscle power and train the balance. Minnis (2017) has mentioned early rehabilitation is
really important to regain the function of the leg and resume in active lifestyle. There are
protocols that the patient and physiotherapist need to follow as shown in the table below.
Timeline Activity Treatment
Work on bending (flexing)

Post-op day
Rest. Ask for help getting out of bed. Walk and straightening (extending)
1 (day of
a short distance with the help of a PT. your knee, using a CPM
surgery)
machine, if prescribed.
Stand up, sit, and change locations with

Work on achieving full
Post-op day assistance. Walk an increased distance
extension. Increase knee
2 using a walker. Climb a few steps at a time
flexion by at least 10 degrees.
with the help of a PT.
Stand up and sit with little to no assistance.

Post-op day Achieve at least 70–90
Walk at least 25 feet using a walker or
3 to degrees of flexion, with or
crutches. Go up and down stairs using
discharge without CPM.
walker or crutches.
Walk and take stairs for longer distances

Continue regular rehab
without an assistive device. Complete at-
sessions to monitor and
home exercises to increase strength and
improve mobility and range
Week 1–3 range of motion.
of motion. Use ice and a CPM
machine at home, if
prescribed.
4
Walk and take stairs for extended distances

Continue regular rehab
on your own. Continue home exercises and
sessions to monitor and
Week 4–6 resume household chores and activities.
increase strength and
Return to work and begin driving with a
flexibility.
recommendation from your PT or surgeon.
Continue rehab for strength

Walk for longer periods, use a stationary
and endurance training and
Week 7-12 bike, and continue prescribed exercises at
work to achieve a range of
home. Return to low-impact activities.
motion of 0–115 degrees.
LITERATURE REVIEW
According to the American Academy of Orthopedic Surgeons as cited in Morrison (2017),

ninety percent of people who have a knee replacement have a lot less pain. Most of these
people are able to perform daily activities and stay active. Pedersen, Mehnert, Johnsen,
Husted, Sorensen (2011) found that only 1.2 percent of people getting a TKR were
hospitalized for blood clots within ninety days of surgery. Men over the age of 70 have the
highest risk of blood clots. Cases of osteolysis which is the plastic or metal fragments are
released from the knee implant into the body and cause inflammation but it is uncommon. In
most cases, patient can resume many of normal activities after about 12 weeks. However, be
sure to check with the doctor before starting a new sport or physical activity. Staying active
will also help the patients strengthen the knee and make it more likely to function well for
many years (Bubnis, 2017).
CASE STUDY
DEMOGRAPHIC DATA
Name : Datin C RN: 11610**

Age: 75 y/o Date of refer : 22nd October 2018
Sex : Female Date of Ax. : 22nd October 2018
Dr. Diagnose : Post Op 21 days right TKR Dr. Mx : TKR operation on 3/10/2018 and
refer to physiotherapy
SUBJECTIVE ASSESSMENT
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PATIENT’S Pt c/o unable to straight the Rt knee

PROBLEM Pt c/o pain at the right leg during standing up
Pt c/o easy fatigue during prolong walking
PAIN 0 1 2 3 4 5 6 7 8 9 10
SCALE Numerical scale: 0/10 – Now
1/10- standing up
Nature of pain : aching pain
Area: right lateral aspect of proximal fibula
Agg: changing position from sitting to standing
Ease : Straight the Rt leg and put the ice pack (pain reduce after 2 minute)
24 hrs; am
pm on ocassion
Night
Irritability : Low
6
Body Chart
R L
R
L
1/10
Aching pain
Agg: Standing up
Ease: apply ice
pack
CURRENT Gradual onset of knee pain and it became worsen since 2 years ago. Pt take
HISTORY injection on 2016 but the pain did not subside until this year. Operation rt
TKR done on 3/10/2018. Then, doctor refers her to physiotherapy for ROM
and strengthening exs.
PAST Pt has h/o knee pain over 20 years and she rely on glucosamine.
HISTORY
FAMILY Her late mother has Knee OA
HISTORY
SOCIAL Marital status: married, live w/ husband
HISTORY Occupation : Housewife (ex-staff nurses)
Nature of work: Cleaning, washing, cooking
Hobby: walk around taman gelora
7
Lifestyle: active
House: single storey
Toilet : sitting
Alcohol : No
Smoking: No
FUNCTION Pt walk using walking frame and claim does not confident.
AL Pt unable to prolonged walking (>50 metre)
ACTIVITY Pt able to go toilet independently with using walking frame.
SPECIAL General health: well and healthy
QUESTION PMHx/ surgery: Pt has HPT since 30 years ago
Investigation:
Xray (rt knee) done on 7/10/2018 at HTAA.
Finding; no abnormality
Medication: HPT medication
Hearing aid/ pacemaker : No
OBJECTIVE ASSESSMENT
GENERAL A small and thin old Chinese lady comes to physiotherapy

OBSERVATION department using walking frame accompanied by her
husband. .
LOCAL OBSERVATION Swelling at rt knee
Dry scar at rt ant. Knee
No redness
No deformity
Bruising at ant rt knee
PALPATION Tenderness at rt lat. Prox. fibula
Mild warmness at rt. Ant. patella
Ms spasm at rt. Tibialis anterior
ROM
Joint Right Left
Knee Active Passive Active
Flexion 10 ˚ -80 ˚ 10 ˚ -95˚ AFROM
Extension Lag 10 ˚ - AFROM
:. Reduce ROM of rt knee d/t immobilisation
8
MUSCLE POWER Muscle Rt Lt

Quadriceps 3/5 5/5
Hamstring 3/5 3/5
Iliapsoas 3/5 4/5
Gluteus Medius 3/5 4/5
Gluteus Maximus 3/5 3/5
:.Reduce muscle power d/t lack of movement/lack of muscle

activity
CLEARING TEST ROM
Joint Rt Lt
Hip Flexion
Extension
Abduction
Int. rotation AFROM AFROM
Ext. rotation
Ankle D/flexion
P/flexion
Inversion AFROM AFROM
Eversion
SWELLING Level Rt Lt Difference

MEASUREMENT Mid patella 35 cm 33.5cm 1.5cm
:.Swelling at rt knee d/to inflammatory process/post op
MUSCLE GIRTH Level Rt Lt Difference

5cm above 36.5cm 34 cm 2.5cm
suprapatella
10cm above 38 cm 35 cm 3 cm
suprapatella
15cm above 40 cm 39.5 cm 1.5 cm
suprapatella
12cm below 29.5 cm 29 cm 0.5 cm
apex patella
:. Muscle wasting at Lt leg d/t weakness
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ACESSORY MOVEMENT Patella mobility

Right Good Good Left
Good Good Fair
Good Good
LEG LENGTH
DISCREPANCY
Type Rt Lt Difference
True leg 73 cm 73cm 0 cm
length
Apperent leg 82 cm 82 cm 0 cm
length
ANALYSIS
PHYSIOTHERAPIST’S IMPRESSION 1. Pain at Rt knee d/t jt stiffness

2. Swelling at Rt knee d/t inflammatory
process
3. Reduce ROM at Rt knee d/t
immobilise
4. Reduce ms power Rt leg d/t lack of
ms activity
5. Mild ms wasting Lt leg d/t ms
weakness
6. Reduce functional activity d/t pain
SHORT TERM GOAL 1. To reduce pain at Rt knee within 4/7
2. To reduce swelling Rt knee within 2/7
3. To increase ROM at Rt knee within
4/7
4. To improve ms power Rt leg within
1/52
LONG TERM GOAL 1. To improve functional ADL such as
10
prolonged walking within 2/12
PLAN OF TREATMENT 1. Pain Mx

2. Stretching exs
3. Active assisted exs
4. Active movt
5. Strengthening exs
6. Scar massage
7. Pt edu
INTERVENTION
Intervention Description Evidence base
1) Pain Mx - Pt half ly, apply cold pack Cryotherapy used after TKR appeared to
on ant. Rt knee, 10 min decrease the need for narcotic medication
from hospital discharge to 2 weeks post-
operatively. There was also a trend toward a
greater distance walked in the 6MWT (Su et
al., 2012)
2) Scar -Pt half ly, do scar massage Scar Massage can increase active range of
Massage on pt, circular massage and motion (ROM) but over four weeks, it does
scar mobilising, 1 min not effective to improve the ROM (Elvery,
2006).
3) Active -Pt pr ly, do Rt knee flex, Physical therapy intervention such as range of
assisted exs with Lt leg assist Rt leg, 5s motion exercise show short term
hold, 10 rep improvements in physical function (Artz et
-Pt sitt on bed, do Rt heel al., 2015)
slide using ball, 10 rep.
4) - Pt p rly, do active Rt knee Muscle power can be improved by
Strengthening flex, 10s hold, 10 rep. progressive strengthening exercise. There are
ex -Pt sup ly, do Rt SQE, put significant increase muscle power after
towel under ankle, 10s exercise the targeted
hold, 10 rep. muscle.(Sattelmayer,2016)
-Pt sup ly, do Rt hip flex,
5s hold, 10 rep.
5) Pt edu/HEP - teach and encourage pt to Home exercise programme can enhance
do exs 3x/day. patient quality of life and prevent secondary
-educate pt to do scar complication of stroke. (Mayo, 2016)
massage at home.
11
EVALUATION 1. Pt able to bend knee from 80˚ to 90˚

actively after doing exercise
2. Pt unable to do IRQ actively
REVIEW 1. to assess pt Rt knee ROM
2. to assess pt Ms power
3. to assess pt balance
FOLLOW UP (29th Oct 2018)
SUBJECTIVE 1. Pt c/o still pain at Rt knee (PS: 1/10) but much better than
ASSESSMENT previously
2. Pt c/o still unable to fully bend Rt knee and weakness
PAIN SCALE 0 1 2 3 4 5 6 7 8 9 10
Numerical scale: 0/10 – Now
1/10- standing up
Ease : Straight the Rt leg and put the ice pack (pain reduce after 2
minute)
24 hrs; am
pm on ocassion
Night
Irritability : Low
FUNCTIONAL Pt walk using walking frame and claim does not confident.
ACTIVITY Pt unable to prolonged walking (>100 metre)
Pt able to go toilet independently with using walking frame.
OBJECTIVE Ax GENERAL A small and thin old Chinese lady comes to
OBSERVATION physiotherapy department using walking
frame accompanied by her husband. .
LOCAL Swelling at rt knee
OBSERVATION Dry scar at rt ant. Knee
12
No redness
No deformity
ROM
Joint Right Left
Flexion 10 ˚ -90 10 ˚ -95˚ AFROM
˚
Extension Lag 10 - AFROM
˚
:. Pt having improvement Rt knee flexion
ROM
MUSCLE POWER Muscle Rt Lt
Quadriceps 3/5 5/5
Hamstring 3/5 3/5
Iliapsoas 3/5 4/5
Gluteus 3/5 4/5
Medius
Gluteus 3/5 3/5
Maximus
:.Reduce muscle power d/t lack of

movement/lack of muscle activity

MEASUREMENT Mid 34.5 33.5cm 1 cm
patella cm
:. Pt having reduced Rt knee swelling
:.Swelling at rt knee d/to inflammatory
process/post op
13

5cm above 35.5cm 34 1.5cm
suprapatella cm
10cm above 36 cm 35 1 cm
suprapatella cm
15cm above 38.5 cm 39.5 1 cm
suprapatella cm
12cm 29 cm 29 0 cm
below apex cm
patella
:. Pt having improvement in ms girth
BALANCE TEST Romberg test:
√ Pt start having sway movement on 6th

second
√ Pt able to stay for 30 sec w/o fall
:.Pt having sway movement during Romberg

test d/t LL weakness
ANALYSIS PT’s Impression Improvement
1. 1.Pain at Rt knee d/t jt stiffness -
2. Swelling at Rt knee d/t Pt having reduced in Rt

knee swelling
inflammatory process
3. Reduce ROM at Rt knee d/t Pt having improvement

in Rt knee flexion ROM
immobilise
4. Reduce ms power Rt leg d/t -

lack of ms activity
5. Mild ms wasting Lt leg d/t ms Pt having improvement
in Rt leg ms girth
weakness
14
6. Pt having sway movement -

during Romberg test d/t LL
weakness
PLAN OF 1. Pain Mx
TREATMENT 2. Stretching exs
4. Active movt
6. Scar massage
7. Balance training
8. Pt edu
INTERVENTION Intervention Description Evidence base
1) Pain Mx - Pt half ly, Cryotherapy used after TKR

apply cold pack appeared to decrease the need
on ant. Rt knee, for narcotic medication from
10 min hospital discharge to 2 weeks
post-operatively. There was also
a trend toward a greater distance
walked in the 6MWT (Su et al.,
2012)
2) Scar -Pt half ly, do Scar Massage can increase
Massage scar massage on active range of motion (ROM)
pt, circular but over four weeks, it does not
massage and effective to improve the ROM
scar mobilising, (Elvery, 2006).
2 min
3) Stretching - Pt half ly, Patients with chronic

Exs straight both musculoskeletal pain
knee, stretch rt demonstrate an increased
& lt knee using tolerance to stretch after three
stretch robe, weeks of static stretching (Page,
15s, 10 rep 2012).
-Pt pr ly. Stretch
rt & lt quads,
bending knee
assist by other
leg, 15s hold, 10
15
sec
3) Range of -Pt sitt on bed, Physical therapy intervention

motion do Rt heel on such as range of motion
exercise bed,flex and ext exercise show short term
the knee, 10 rep. improvements in physical
-Pt do static function (Artz et al., 2015)
cycling, 10 min
4) -Pt sup ly, do Rt Muscle power can be improved
Strengthening SQE, put towel by progressive strengthening
ex under ankle, 10s exercise. There are significant
hold, 10 rep. increase muscle power after
-Pt sitt, do Rt exercise the targeted
hip flex with muscle.(Sattelmayer,2016)
bend the
knee,10 rep.
5) Pt - teach and Home exercise programme can
edu/HEP encourage pt to enhance patient quality of life
do exs 3x/day. and prevent secondary
-educate pt to do complication of stroke. (Mayo,
scar massage at 2016)
home.
EVALUATION 1. Pt still having lag and slow improvement
5. to assess pt balance
FOLLOW UP (31st OCT 2018)
SUBJECTIVE Pt claim had much improvement on rt knee

ASSESSMENT Pt claim pain at rt knee still the same
Pt claim she more confident to walk w/o using walking frame
16
PAIN SCALE 0 1 2 3 4 5 6 7 8 9 10
Numerical scale: 0/10 – Now
1/10- standing up
Ease : Straight the Rt leg and put the ice pack (pain reduce after 2
minute)
24 hrs; am
pm on ocassion
Night
Irritability : Low
FUNCTIONAL Pt walk using a stick

ACTIVITY Pt unable to prolonged walk more than 500 metre
OBJECTIVE Ax GENERAL A small and thin old Chinese lady comes to
OBSERVATION physiotherapy department using walking frame
accompanied by her husband. .
LOCAL Swelling at rt knee
OBSERVATION Dry scar at rt ant. Knee
No redness
No deformity
ROM
Joint Right Left
Flexion 5 ˚ -105˚ 5˚ -110˚ AFROM
Extension Lag 5 ˚ - AFROM
:.Pt having improvement in Rt knee ROM
17
MUSCLE Muscle Rt Lt
POWER Quadriceps 4/5 5/5
Hamstring 4/5 4/5
Iliapsoas 4/5 4/5
Gluteus 4/5 within ROM 4/5
Medius
Gluteus 4/5 4/5
Maximus
:. Pt having improvement of ms power on Rt

and Lt leg
:.Reduce muscle power d/t lack of
movement/lack of muscle activity
MEASUREMENT Mid 34 cm 33.5cm 0.5cm
patella
:.Pt had reduced swelling on rt knee
:.Swelling at rt knee d/to inflammatory
process/post op

5cm above 35.5cm 34 cm 1.5cm
suprapatella
10cm above 36 cm 35 cm 1 cm
suprapatella
15cm above 38.5 cm 39.5 1 cm
suprapatella cm
12cm below 29 cm 29 cm 0 cm
apex patella
:. Pt had no improvement on ms girth
BALANCE TEST Romberg test:
√ Pt start having sway movement on 9th second

√ Pt able to stay for 30 sec w/o fall
:. Pt had mild improvement in balance standing

:.Pt having sway movement during Romberg
test d/t LL weakness
18
ANALYSIS PT’s Impression Improvement
Pain at Rt knee d/t post- -

surgery/ms tightness
Swelling at Rt knee d/t -

inflammatory process
Reduce ROM at Rt knee d/t Pt had much improvement on

Rt knee ROM
immobilise
Reduce ms power Rt leg d/t lack Pt had much improvement in

muscle power of Rt leg
of ms activity
Mild ms wasting Lt leg d/t ms Pt did not had improvement
in ms girth
weakness
Pt having sway movement during :. Pt had mild improvement
in balance standing
Romberg test d/t LL weakness
PLAN OF 1. Pain Mx
TREATMENT 2. Stretching exs
4. Active movt
6. Scar massage
7. Pt edu
INTERVENTION Intervention Description Evidence base
1) Pain Mx - Pt half ly, apply Cryotherapy used after TKR

cold pack on ant. Rt appeared to decrease the need
knee, 10 min for narcotic medication from
- Pt half ly, do STM hospital discharge to 2 weeks
& deep friction post-operatively. There was
massage on Rt also a trend toward a greater
quads, 2 min distance walked in the 6MWT
(Su et al., 2012)
19
3) ROM exs -Pt pr ly, do Rt knee Physical therapy intervention

flex, with Lt leg such as range of motion
assist Rt leg, 15s exercise show short term
hold, 10 rep improvements in physical
-Pt sitt on chair, do function (Artz et al., 2015)
Rt heel slide using
ball, actively push
rt knee
downward,10s
hold, 10 rep.
- Pt do static
cycling, 10 min
4) Stretching - Pt half ly, straight Patients with chronic
Exs both knee, stretch rt musculoskeletal pain
& lt knee using demonstrate an increased
stretch robe, 15s, 10 tolerance to stretch after three
rep weeks of static stretching
-Pt pr ly. Stretch rt (Page, 2012).
& lt quads, bending
knee assist by other
leg, 15s hold, 10
sec
5) -Pt sup ly, do Rt Muscle power can be
Strengthening SQE, put towel improved by progressive
ex under ankle, 10s strengthening exercise. There
hold, 10 rep. are significant increase
-Pt crk ly, contract muscle power after exercise
rt gluteus ms, 10s the targeted
hold, 10 rep muscle.(Sattelmayer,2016)
-Pt sup ly, do Rt hip
flex, 5s hold, 10
rep.
-Pt st at parallel bar,
do step up and
down, the rt leg
fixed, move the lt
leg up and down,
10 rep.
6) Pt edu - teach and Home exercise programme
encourage pt to do can enhance patient quality of
exs 3x/day. life and prevent secondary
complication of stroke.
(Mayo, 2016)
EVALUATION 1. Pt need hand support when doing step up and down
20

3. to assess TUG
CONCLUSION
Generally, from the first visit, this patient unable to do full knee extension, knee flexion less
than 90˚ and muscle weakness. This patient has severe quadriceps (vastus medialis oblique)
weakness because she still unable to do inner range quads (IRQ) until the third visit.
However, she had improvement in knee flexion active range of motion (ROM) and can
achieve from 80 ˚ to 110˚ which approximately near to the 115 ˚ (the normal ROM og
knee flexion after total knee replacement surgery). Furthermore, within seven weeks
post operation, she had improve in static and dynamic standing balance which had been
examine by doing the outcome measure such as, Romberg test, Time Up and Go Test and
Four Square Step Test. Hence, physiotherapists play a vital role to enhance patient
physical functional ability throughout doing exercise such as, mobilising exercise,
stretching and mobilising exercise.
REFERENCES
Artz, N. (2015). Effectiveness of physiotherapy exercise following total knee replacement :

systematic review and meta-analysis. https://doi.org/10.1186/s12891-015-0469-6
Commentary, C. (n.d.). CLINICAL COMMENTARY CURRENT CONCEPTS IN MUSCLE

STRETCHING, 7(1), 109–119.
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replacement
Matassi, F., Duerinckx, J., Vandenneucker, H. et al. Knee Surg Sports Traumatol Arthrosc
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Mayo, N. E. (2016). Rehabilitation at Home: Lessons Learned and Ways Forward.

Stroke, 47(6), 1685–1691. https://doi.org/10.1161/STROKEAHA.116.011309
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Morrison W. (2017, October, 23). Healthline. Risks and Complications of Total Knee
Replacement Surgery. Retrieved from https://www.healthline.com/health/total-knee
replacement-surgery/risks-complications
Scenario, C. (2006). There is fair evidence ( level 2b ) to support the use of massage
following surgical and traumatic hand injuries to increase wrist active ROM Prepared
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Shin, T. M. and Bordeaux, J. S. (2012), The Role of Massage in Scar Management: A

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Sullivan D. (2016, February, 18). Healthline. Double Knee Replacement Surgery. Retrieved
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Tortora, G. J., & Derrickson, B. (n.d.). Principles of Anatomy and Physiology, 14th Edition.
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Case Study TKR

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Case Study TKR

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Aimi Nabilah binti Sukor (1515950) Clinical Physiotherapy II (AHP3126)

DEPARTMENT OF PHYSICAL REHABILITATION SCIENCES

RIGHT TOTAL KNEE REPLACEMENT

CLINILCAL POSTING II AHP3126

NAME: AIMI NABILAH BINTI SUKOR

MATRIC NO: 1515950

PROGRAM: BACHELOR OF PHYSIOTHERAPY

LEVEL: 4TH YEAR SEMESTER 1

Timeline Activity Treatment

Work on bending (flexing)

Stand up, sit, and change locations with

Stand up and sit with little to no assistance.

Walk and take stairs for longer distances

Walk and take stairs for extended distances

Continue rehab for strength

According to the American Academy of Orthopedic Surgeons as cited in Morrison (2017),

Name : Datin C RN: 11610**

PATIENT’S Pt c/o unable to straight the Rt knee

GENERAL A small and thin old Chinese lady comes to physiotherapy

MUSCLE POWER Muscle Rt Lt

:.Reduce muscle power d/t lack of movement/lack of muscle

SWELLING Level Rt Lt Difference

MUSCLE GIRTH Level Rt Lt Difference

ACESSORY MOVEMENT Patella mobility

Good Good Fair

PHYSIOTHERAPIST’S IMPRESSION 1. Pain at Rt knee d/t jt stiffness

prolonged walking within 2/12

PLAN OF TREATMENT 1. Pain Mx

Intervention Description Evidence base

EVALUATION 1. Pt able to bend knee from 80˚ to 90˚

FOLLOW UP (29th Oct 2018)

:.Reduce muscle power d/t lack of

SWELLING Level Rt Lt Difference

MUSCLE GIRTH Level Rt Lt Difference

√ Pt start having sway movement on 6th

:.Pt having sway movement during Romberg

ANALYSIS PT’s Impression Improvement

1. 1.Pain at Rt knee d/t jt stiffness -

2. Swelling at Rt knee d/t Pt having reduced in Rt

3. Reduce ROM at Rt knee d/t Pt having improvement

4. Reduce ms power Rt leg d/t -

6. Pt having sway movement -

INTERVENTION Intervention Description Evidence base

1) Pain Mx - Pt half ly, Cryotherapy used after TKR

3) Stretching - Pt half ly, Patients with chronic

3) Range of -Pt sitt on bed, Physical therapy intervention

FOLLOW UP (31st OCT 2018)

SUBJECTIVE Pt claim had much improvement on rt knee

FUNCTIONAL Pt walk using a stick

:. Pt having improvement of ms power on Rt

MUSCLE GIRTH Level Rt Lt Difference

BALANCE TEST Romberg test:

√ Pt start having sway movement on 9th second

:. Pt had mild improvement in balance standing

ANALYSIS PT’s Impression Improvement

Pain at Rt knee d/t post- -

Swelling at Rt knee d/t -

Reduce ROM at Rt knee d/t Pt had much improvement on

Reduce ms power Rt leg d/t lack Pt had much improvement in

1) Pain Mx - Pt half ly, apply Cryotherapy used after TKR

3) ROM exs -Pt pr ly, do Rt knee Physical therapy intervention

REVIEW 1. to assess pt Rt knee ROM

Artz, N. (2015). Effectiveness of physiotherapy exercise following total knee replacement :