Who can and who can’t kneel after knee replacement

Ross A. Hauser, MD.

Who can and who can’t kneel after knee replacement

For some people, there may be no choice, they will need a knee replacement. One of the problems encountered after knee replacement is the patient’s inability to kneel. What makes this problem so frustrating for some, as we will see in the research below, is that there does not seem to be a consistent reason why people who should be able to kneel after knee replacement cannot.

Now if you are exploring a knee replacement, we typically find that people who can still bend their knees, are able to put weight on their knee in a kneeling position, and are able to lift themselves up from bed, out of a car, or from a low position, are realistically good candidates for our non-surgical treatments. However, each individual varies and this is not to say this would be characteristic of everyone. You can contact us below and we can help assess what is happening in your case.

Now if you already had a knee replacement and are running into kneeling challenges, let’s cover some research and clinical observations.

Article Summary:

• Kneeling ability is consistently the poorest patient-rated outcome after total knee replacement.
  • Doctors don’t know who can and who can’t kneel after knee replacement.
  • Predictive factors of which patients would be able to kneel after total knee replacement and which patients would not.
• I thought I would be able to kneel after knee replacement. I can’t. “An expectation of the total knee replacement to improve patients’ ability to kneel was associated with lower odds of satisfaction.”
• I don’t kneel because I do not want to damage the hardware.
• 60-80% of patients report difficulty kneeling after knee replacement or an inability to kneel.
• Maybe it is not in your knee but in your head. Nerve pain versus in-your-head pain.
  • People should be able to kneel after knee replacement – why aren’t they? Research: It has nothing to do with a knee replacement.
  • When a patient says “I just can’t kneel.”
• So can we do anything about it? When it is a problem of the knee replacement knee?
• The unexplained noises my knee is making.
• How can we help these problems? The often overlooked and ignored cause of knee instability and possible causes of inability to kneel after knee replacement – the Knee Ligaments.
• A realistic assessment of what we can do to help after knee replacement.
• It’s not my knee replacement that is the problem, it is my other knee. Expanding on the “other knee” problem.

Kneeling ability is consistently the poorest patient-rated outcome after total knee replacement

A July 2019 paper (1) from the Bristol Medical School at the University of Bristol that we also cite below offers us a good introduction to the problems of kneeling following a total knee replacement.

“Kneeling ability is consistently the poorest patient-rated outcome after total knee replacement, with 60-80% of patients reporting difficulty kneeling or an inability to kneel. Difficulty kneeling impacts many activities and areas of life, including activities of daily living, self-care, leisure, and social activities, religious activities, employment, and getting up after a fall. Given the wide range of activities that involve kneeling, and the expectation that this will be improved with surgery, problems kneeling after total knee replacement are a source of dissatisfaction and disappointment for many patients.” the ability to kneel goes beyond religious observance. It is the ability to get up after a fall. It is the ability to care for oneself. It is the ability to preserve the other knee that is not bad enough to get replaced.

For many people, the ability to kneel goes far beyond religious observance. In many patients we see, who had a knee replacement, or are exploring their options, little information is given or was given in regard to their ability or later to find out, inability to kneel. This became, or became crucial when they realized the ability to kneel, is the ability to get up after a fall and put pressure on the bent knee and their ability to go about their daily chores.

We hear things like this. The grandmother

I had a knee replacement. I was told that I could not kneel anymore, if I had to kneel, I had to put a lot of padding down on the ground. I like to clean, I like to get on the floor and scrub. My washer and dryer are front loaders, before I had knee pain I would sometimes find it easier to kneel rather than bend over. I have grandkids, I like getting on the floor with them to play.

I was told that the hardware from the knee replacement may make kneeling painfully. I was reassured that I would not damage the hardware if I knelt but I should use the padding. So I got my husband to help me and I tried to start practicing kneeling at home. I put a lot of pads down, it was uncomfortable, but the real problem was I had no idea how to get up. My “good knee,” the knee that did not need the knee replacement or was not that far gone enough to get one, and my new knee, because of muscle atrophy following the surgery, was neither strong enough to get me up again. I was on the ground, I could not get up by myself.

We hear things like this. The home improvement construction guy

I had to get a knee replacement. I was very aggressive in my rehab as I had to get back to work.  I came back sooner than I should have and was lucky that it did not set me back. My problem is that I am overcompensating now and “my good knee,” is deteriorating.

Let’s stress again that many people have great results with their knee replacement. They do not have problems with kneeling or other complication. These are people we do not typically see in our office. We see the people for whom the expectation of what their knee replacement could and could not do for them was not met.

For more information on getting back to work please see our article: How fast can I return to work after knee replacement? 15 to 30% of patients do not return to work 

Doctors don’t know who can and who can’t kneel after knee replacement

A September 2021 paper in The Bone & Joint Journal (10) investigated the ability to kneel after total knee replacement without patellar resurfacing and its effect on patient-reported outcome measures. Secondary aims included identifying which kneeling positions were most important to patients, and the influence of radiological parameters on the ability to kneel before and after total knee replacement.

• There were 209 patients who underwent total knee replacement without patellar resurfacing.
• Among other outcome scores: The ability to achieve four kneeling positions was assessed including a single-leg kneel, a double-leg kneel, a high-flexion kneel, and a praying position.
• The majority of patients were male and were considered obese.

Results:

• The ability to kneel in the four positions improved in between 29 (19%) and 53 patients (35%) after total knee replacement but declined in between 35 (23%) and 46 patients (30%).
• Single-leg kneeling was most important to patients.
• After total knee replacement,
  • 62 patients (41%) were unable to achieve a single-leg kneel,
  • 76 (50%) were unable to achieve a double-leg kneel,
  • 102 (68%) were unable to achieve a high-flexion kneel and
  • 61 (40%) were unable to achieve a praying position.
• Posterolateral cartilage loss (side and top rear of knee) significantly affected preoperative deep flexion kneeling.
• A postoperative inability to kneel was significantly associated with worse outcomes and patient satisfaction.

A February 2021 study comes to us from the Australian National University. In this paper, the researchers suggest that despite patients’ desires to kneel after knee replacement, there is no evidence or guidelines to offer patients on which knee replacement hardware would be best for them. Here is what the researchers wrote in the journal Knee Surgery, Sports Traumatology, Arthroscopy.”(2)

“Modern total knee replacement prostheses are designed to restore healthy kinematics (knee movement) including high flexion (bending). Kneeling is a demanding high-flexion activity. There have been many studies of kneeling kinematics using a plethora of implant designs but no comprehensive comparisons.  .  .The aim of this systematic review was to determine whether there are any differences in the kinematics of kneeling as a function of total knee replacement design.”

In this study, the researchers examined 26 previously published articles on different knee replacement implant designs. What they found were limited findings. Too many designs, and too many differently conducted studies. What does this mean to the patient who asks their surgeon about their ability to kneel after knee replacement? The researchers concluded: “There remains a need for high-quality prospective comparative studies to directly compare designs using a common method.” In other words, we can’t tell you for sure.

Predictive factors of which patients would be able to kneel after total knee replacement and which patients would not

In October 2021, doctors at McMaster University in Ontario and the University of Toronto published their findings in the journal Knee surgery and related research (9) on predictive factors of which patients would be able to kneel after total knee replacement and which patients would not, or, have a much longer time being able to kneel after surgery. Here is what they wrote: “(This study)  aimed to quantify the number of patients able to kneel after total knee replacement and determine the effectiveness of surgical approaches and prosthesis designs in improving kneeling results. Pooled results showed that kneeling ability increased with a longer follow-up duration, with 36.8% of patients able to kneel at a minimum of 1-year follow-up and 47.6% able to kneel at a minimum of 3 years follow-up. Among comparative studies, a shorter incision length greatly improved the odds of kneeling compared with a longer incision. . . ” However the study authors also stated: “Prior to total knee replacement, 80–95% of patients have high expectations of being able to kneel after surgery. When high preoperative expectations are not met, they can negatively impact patient satisfaction. This study found that approximately two-thirds of patients are unable to kneel after at least 1-year post surgery and around half of the patients cannot kneel 3 or more years after total knee replacement. . . Increased numbness—from sensory nerve damage during surgery—is correlated with poorer kneeling ability and is a common symptom reported by patients unable to kneel.”

I thought I would be able to kneel after knee replacement. I can’t. “An expectation of the total knee replacement to improve patients’ ability to kneel was associated with lower odds of satisfaction.”

Let’s remind ourselves here that many people have very successful knee replacement surgeries and they can function better afterward. These are not the patients we see. We see patients who had an over-expectation of what their knee replacement could do for them and then they found out, the knee replacement could not help them do all the things they thought it could.

Led by researchers at the University of Toronto and the University of Calgary, a 2021 study published in the journal Arthritis & Rheumatology (3) assessed the relationship between patients’ expectations for total knee replacement and satisfaction with surgical outcomes.

What the researchers did was look at patients who received total knee replacement surgeries and then they gave questionnaires that measured depression scale, body mass index [BMI], comorbidities (other health concerns), and prior joint replacement), at 1-year post-total knee replacement to assess overall satisfaction with total knee replacement results.

The researchers then divided up responses to see what the patients considered important factors in their satisfaction or dissatisfaction with the knee replacement.

Here is what 1,266 patients who had a knee replacement had to say:

• 74.7% of patients were very satisfied,
• 17.1% were somewhat satisfied,
• and 8.2% were dissatisfied.

An expectation of the total knee replacement to improve patients’ ability to kneel was associated with lower odds of satisfaction

An expectation of the total knee replacement to improve psychological well-being was associated with lower odds of satisfaction.

Conclusion: “In patients with total knee replacement, preoperative expectations regarding kneeling and psychological well-being were significantly associated with the level of total knee replacement satisfaction at one year.”

I don’t kneel because I do not want to damage the hardware

The idea that doctors are not sure which knee replacement hardware will help the patient the most in their desire to kneel is reflected in the idea that maybe patients should avoid kneeling.

A June 2021 update study in The Journal of Knee Surgery (4) comes to us from researchers at Massachusetts General Hospital, the University of Miami Miller School of Medicine, and the Rothman Institute of Orthopaedics. In their study of 404 patients who had a knee replacement and difficulty kneeling the researchers found:

• Sixty percent of patients were unable to kneel after a total knee replacement
  • Men and patients with occupations or hobbies requiring kneeling were more likely to kneel after surgery.
  • People who had kneeling difficulties had:
    • Too much weight or a high body mass index.
    • It was too painful to kneel
    • They did not have physical inability (the strength to get up from a kneeling position)
    • Fear of damaging the prosthesis. (This is a recurring theme in research including the next study).

60-80% of patients reported difficulty kneeling or an inability to kneel

In the research from the University of Bristol, (1) cited above, the doctors noted 60-80% of patients reported difficulty kneeling or an inability to kneel after knee replacement. The problem beyond the inability to heal is why can’t these people kneel. They should be able to. So the researchers speculated the following points.

• More research is needed to understand if and how surgical factors contribute to difficulty kneeling after total knee replacement.
• Discrepancies between patients’ self-reported ability to kneel and observed ability suggest that patients can kneel but elect not to.
  • Reasons for this are multifactorial, including:
    • knee pain/discomfort,
    • numbness,
    • fear of harming the prosthesis,
    • co-morbidities and recommendations from health professionals.
• There is currently no evidence that there is any clinical reason why patients should not kneel on their replaced knee, and reasons for not kneeling could be addressed through education and rehabilitation. There has been little research to evaluate the provision of healthcare services and interventions for patients who find kneeling problematic after.”

Maybe it is not in your knee but in your head. Nerve pain versus in-your-head pain

We have been helping people with a lot of musculoskeletal difficulties for 28 years. The number of people who have been in our office because they were constantly told that their problems were not in their joints but in their heads was vast. Many times we find the problems are not in the patient’s head but are actually in the joints.

This concept that a patient is having difficulty kneeling because they have a fear of kneeling or rather a fear of the pain kneeling may cause them is not a new idea but it is the subject of a lot of current research. A study from March 2019 published in the medical journal Knee (5) from doctors in the United Kingdom asked the question, Why do patients not kneel after total knee replacement? Is neuropathic pain a contributing factor?

Here are the summary points of this research:

• Despite kneeling being an important and valued function of the knee, a proportion of patients are unable to kneel following knee replacement. This study explores the reasons for this and assesses whether neuropathic (nerve) pain is a contributing factor or something else.

The findings:

• 88% of patients in this study had tried kneeling post-operatively.
• There was no change in kneeling ability for the whole study group from pre- to post-operatively. (In other words, the patients had the same ability to kneel before and after the surgery).
• Patient reasons for not kneeling varied. However, the average test scoring for pain and function for all kneeling abilities lay within the nociceptive (the idea that kneeling will be painful) rather than the neuropathic (the pain is coming from the nerves) range.

Conclusion:

“Kneeling ability varies greatly post-knee replacement, and is multifactorial. Greater pain is a contributing factor to the inability to kneel postoperatively, but this appears to be nociceptive rather than neuropathic in nature.”

Comment: If kneeling is an important part of your life, you should discuss your ability to do so with your doctors before you being any treatment.

People should be able to kneel after knee replacement – why aren’t they? Research: It has nothing to do with the knee replacement

Let’s look at a January 2019 study in the Journal of Knee Surgery. (6) It comes from the Department of Orthopaedic Surgery, Johns Hopkins University.

Here are the summary points:

• The ability to kneel is one of the many patient goals after total knee replacement.
• Given the altered biomechanics of the knee after total knee replacement, the various implant designs, and multiple surgical approaches, there is a need to further understand the patient’s kneeling ability after total knee replacement.
• In patients who do kneel after surgery, data show that an increased range of motion promotes improved kneeling performance. Targeted interventions to encourage kneeling after total knee replacement, including preoperative education, have not shown an ability to increase the frequency with which patients kneel after total knee replacement.
• Reasons for patient avoidance of kneeling are multifaceted and complex. There is no biomechanical or clinical evidence contraindicating kneeling after total knee replacement. There are insufficient data to recommend particular prosthetic designs or surgical approaches to maximize kneeling ability after surgery. Musculoskeletal healthcare providers should continue to promote kneeling to allow patients to achieve maximum clinical benefit after total knee replacement.

When a patient says “I just can’t kneel.”

Let’s look at another study looking for answers, here we have doctors at the University of Bristol  in the United Kingdom publishing in the journal Disability and Rehabilitation, April 2019 (7)

• The researchers here conducted telephone interviews with 56 patients who had extreme difficulty kneeling at 7-10 years after knee replacement.
• Patients were asked about reasons for difficulty kneeling, how it impacted their lives and their experiences of healthcare services.

Results:

• Most people had difficulty kneeling because of pain or discomfort in the replaced knee.
• Many patients described how this limitation affected their daily lives, including housework, gardening, religious practices, leisure activities, and getting up after a fall.
• Patients often adapted to these limitations by finding alternatives to kneeling, assistance from others, or home adaptations.
• Many patients had accepted that they could not kneel, however some still expressed frustration.
• Few patients had consulted with healthcare professionals about kneeling difficulties, and unmet needs included the provision of information about kneeling and post-operative physiotherapy.

Our patient Jeannette had issues with spinal stenosis and problems post-knee replacement.

• Jeannette starts discussing the knee replacement complications at 3:50 in the video. Jeannette is 81 years old.

Jeannette describes a foot-tingling problem. She cannot sit down and relax at the end of the day, it is uncomfortable for her to put her feet up or down because it is tingling. She had a nerve conduction study that shows an injury to her peroneal nerve. The peroneal nerve branches out from the sciatic nerve. As it provides sensation to the front and sides of the legs and to the top of the feet, damage to this nerve would result in burning and tingling or numbness sensation in these areas. Further damage to this nerve would also cause loss of control in the muscles in the leg that help you point your toes upward. This can lead to walking problems and possibly foot drop, the inability to lift the front of the foot or ankle. Knee and hip replacement are leading culprits in the cause of peroneal nerve injury.

In Jeannette’s case, she had two knee replacement surgeries in that knee. After the first knee replacement surgery, the implant started to protrude away from the limb. The knee replacement became loose. The second surgery to fix the first one occurred in 2015.

It was determined after examination that Jeannette’s knee ligaments were loose. Her knee was hypermobile and unstable. This was causing pressure on her peroneal nerve. Knee ligament damage and weakness is also a complication of knee replacement surgery and is discussed further below.

So can we do anything about it? When it is a problem of the knee replacement knee

Can we help you with your continued knee pain after knee replacement surgery? In this article Problems after knee replacement Finding help for post-replacement pain, we will explore the problems identifying the source of knee pain after knee replacement and how identifying and treating soft tissue damage may be the answer to pain after knee replacement.

In this video, Ross Hauser, MD explains the problems of post-knee replacement joint instability and how Prolotherapy injections can repair damaged and weakened ligaments that will tighten the knee. This treatment does not address problems of hardware malalignment that our patient Jeannette described in the video above. 

Summary of this video: A patient with back pain and clicking in the knee

The patient in this video came into our office for low back pain. I did a “straight leg raise test,” on this patient to help determine if his back pain was coming from a herniated disc. During the test I noticed a clicking sound coming from his knee. The patient had a knee replacement. It is very common for us to see patients after knee replacement who have these clicking sounds coming from knee instability. This is not instability from hardware failure. The hardware may be perfectly placed in the knee. It is instability from the outer knee where the surviving ligaments are. I believe that this is why up to one-third of patients continue to have pain after knee replacement.

The unexplained noises my knee is making.

This is something we typically hear in a post-knee replacement patient who is having some challenges.

I started to become concerned when I noticed a clunking and clicking sound coming from my knee. Like metal on metal. My doctor told me that this was no concern, some people who get knee replacements have these “old car,” sounds coming from their knees. Not to worry. My doctor did advise me that the sounds if they continued could be caused by weakened muscles and tendons in my knees and I should consider an exercise program to tighten them up.

I did ask if the knee implant was coming loose. My doctor said, if it were, I would not be able to walk up and down stairs or even put weight on that foot. I would have a lot of swelling and I would feel like my knee may give out. I looked at the doctor and said, BUT I DO HAVE THOSE SYMPTOMS, “Yes you do,” the doctor said, but it is not from implant loosening. You probably just need to strengthen that knee up.

How can we help these problems? The often overlooked and ignored cause of knee instability and possible causes of inability to kneel after knee replacement – the Knee Ligaments.

When a knee replacement is performed, the joint itself has to be stretched out so the surgeons can cut out bone and put it in the prosthesis. When the joint is stretched out, the knee ligaments and tendons that survive the operation will cause pain as they heal from the surgical damage. Sometimes the ligaments and tendons heal well. Sometimes they do not heal as well.

A realistic assessment of what we can do to help after knee replacement

In our clinic, we try to provide information on helping people explore other treatment options before joint replacement. One of those options is simple dextrose Prolotherapy. This regenerative injection technique helps rebuild damaged ligaments and tendons.

Prolotherapy and Platelet Rich Plasma Therapy

We are going to briefly address two treatment options that we offer here at Caring Medical. These are non-surgical, injections. These treatments may help the patient who has difficulty kneeling by restoring stability in a loose and wobbly knee following knee replacement.

Prolotherapy is an injection technique utilizing simple sugar or dextrose which causes a small controlled inflammation at weakened tissue. This triggers the immune system to initiate the repair of the injured tendons and ligaments. Blood supply dramatically increases in the injured area. The body is alerted that healing needs to take place and reparative cells are sent to the treated area of the knee that needs healing. The body also lays down new collagen in the treated areas, thereby strengthening the weakened structures. Once the tendons and ligaments are strengthened, the knee, even one that has been replaced, stabilizes.

Platelet Rich Plasma Therapy is the use of a patient’s blood platelets and healing factors to stimulate the repair of a tendon it is considered when tendon damage is more severe.

When the patients have already had a joint replacement, we will do a physical examination of the knee to assess how we may be able to help.

• Prolotherapy and Platelet Rich Plasma Therapy fix soft tissue, it cannot fix hardware failure,
• Prolotherapy
• and Platelet Rich Plasma Therapy works by stabilizing the knee by strengthening the natural muscle and bone attachments, ligaments, and tendons.

Many of the patients that we see with knee pain after knee replacement have pain on the outside of the knee. This is where the ligaments and tendons are. Most often these connective tissues are damaged and under constant strain. This causes the knee to wobble, be unstable, and cause hypermobility. This pulls and tugs at the ligaments and tendons which causes the patient a lot of pain.

Some patients have nerve irritations, such as Jeannette did in the above video. This nerve irritation can be below or above the knee or along with the kneecap. We would treat these problems with nerve release therapy.

It’s not my knee replacement that is the problem, it is my other knee. Expanding on the “other knee” problem

In Australia, doctors at the University of Wollongong, examining why patients who should be able to kneel after knee replacement, did not kneel, wrote in the Journal of Orthopaedics and Traumatology (8), about the problems of the other, non-replaced knee.

Here is what they found:

• Seventy-two percent of patients in this study could, or thought they could kneel at 12 months post-knee replacement
• However, some did not because of the pain and discomfort they felt during kneeling.
• But, it was not the pain and discomfort in the replaced knee, 75 % of the patients in this study had other health concerns why they could not kneel including obesity, and other health problems, but the number one reason was “problems with the other knee.”

So can we do anything about it? When it is a problem with the other knee?

Clearly knee weakness and instability in the “other knee,” will present problems in kneeling. If your knee is not bad enough for another knee replacement and you would like to explore other options please consider a review of the following information:

The evidence for Prolotherapy Injections for knee osteoarthritis

In this article, we are updating research and clinical observations on the use of Platelet Rich Plasma Therapy (PRP) for the treatment of knee osteoarthritis. We will also explain why PRP may not work and how getting a single PRP injection is NOT PRP Therapy and will usually lead to unsatisfying long-term results.

If this article has helped you understand the problems of obesity and joint pain and you would like to explore Prolotherapy as a possible remedy for your joint pain, ask for help and information from our specialists

References

1 Wylde V, Artz N, Howells N, Blom AW. Kneeling ability after total knee replacement. EFORT open reviews. 2019 Jul;4(7):460-7. [Google Scholar]
2 Lynch JT, Scarvell JM, Galvin CR, Smith PN, Perriman DM. Influence of component design on in vivo tibiofemoral contact patterns during kneeling after total knee arthroplasty: a systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2020 Apr 3:1-21. [Google Scholar]
3 Hawker GA, Conner‐Spady BL, Bohm E, Dunbar MJ, Jones CA, Ravi B, Noseworthy T, Dick D, Powell J, Paul P, Marshall DA. Patients’ Preoperative Expectations of Total Knee Arthroplasty and Satisfaction With Outcomes at One Year: A Prospective Cohort Study. Arthritis & Rheumatology. 2021 Feb;73(2):223-31. [Google Scholar]
4 Sabeh KG, Hernandez VH, Cohen-Levy WB, Ong A, Orozco F, Bennett V, Post Z. The Effects of Patient Occupation, Hobbies, and Body Mass Index on Kneeling after Total Knee Arthroplasty. The journal of knee surgery. 2019 Dec 9. [Google Scholar]
5 Smith JR, Mathews JA, Osborne L, Bakewell Z, Williams JL. Why do patients not kneel after total knee replacement? Is neuropathic pain a contributing factor?. The Knee. 2019 Mar 1;26(2):427-34. [Google Scholar]
6 Amin RM, Vasan V, Oni JK. Kneeling after total knee arthroplasty. The journal of knee surgery. 2019 Jan 2. [Google Scholar]
7 Fletcher D, Moore AJ, Blom AW, Wylde V. An exploratory study of the long-term impact of difficulty kneeling after total knee replacement. Disability and rehabilitation. 2019 Mar 27;41(7):820-5. [Google Scholar]
8 White L, Stockwell T, Hartnell N, Hennessy M, Mullan J. Factors preventing kneeling in a group of pre-educated patients post total knee arthroplasty. Journal of Orthopaedics and Traumatology. 2016 Dec 1;17(4):333-8. [Google Scholar]
9 Nadeem S, Mundi R, Chaudhry H. Surgery-related predictors of kneeling ability following total knee arthroplasty: a systematic review and meta-analysis. Knee Surgery & Related Research. 2021 Dec;33(1):1-7. [Google Scholar]
10 Scott CE, Holland G, Gillespie M, Keenan OJ, Gherman A, MacDonald DJ, Simpson AH, Clement ND. The ability to kneel before and after total knee arthroplasty: the role of the pattern of osteoarthritis and the position of the femoral component. The Bone & Joint Journal. 2021 Sep 1;103(9):1514-25. [Google Scholar]

This article was updated May 30, 2022

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