How fast can I return to work after knee replacement? 15 to 30% of patients do not return to work

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C

How fast can I return to work after knee replacement? 15 to 30% of patients do not return to work

Many people who have total or partial knee replacement have very successful operations. These are not the people we see in our offices. We see the people who:

• Had a knee replacement with less than successful results and is now in a “salvage,” or “revision” stage of their treatment.
• Had a knee replacement with good results but suffer from non-hardware-related knee instability. This would be caused by damaged or weakness to the surviving soft connective tissue of the knee. We will often see a patient in our office who had a knee replacement and that knee is very loose.
  • It is not the hardware or the prosthesis that is loose, it is what is left of the soft tissue of their natural knee that is loose. The soft tissue is the supportive knee ligaments, tendons, and tendon muscle attachments. Often we can strengthen those connective tissues of their natural knee with simple injections which we will discuss below.
• Cannot work from home and knee replacement is not a viable option because they need to work on-site or at their business and they want to delay or avoid the surgery if at all realistically possible.

So the question for many facing knee replacement is not IF they can return to work, but WHEN?

The longer the delay, the greater out-of-pocket expense, lost work time, and lost salary, especially among the self-employed with physically demanding jobs. If you are reading this article, you are researching the realistic expectation of when you can return to work after your knee replacement or you recently had a knee replacement and the recovery has been filled with setbacks.

Again, to be fair, many people have knee replacements that are very successful. This article is for the people who did not enjoy that success.

Patients who had knee replacement talk to us

Typically patients who have concerns about getting back to work after knee replacement are people that have some type of physically demanding job. It may simply be a job where they stand on their feet all day or something more demanding. Regardless there is a concern in the patient about when they will be able to return to work and if they can return to work without fear of what their knee can now take.

Listen to one experience:

I was told 12 weeks before I could return to work. I work in an upscale restaurant and I do stand on my feet all day. I thought I could go back after 8 weeks. I needed to get back to work and 4 weeks’ pay was too much for me to give up, so I came back early. This was a mistake. I feel my knee never strengthened and I had to go back to the surgeon and discuss more options for a staged or phased return to work. My surgeon put me under more restrictions and my recovery is ongoing.

Here is another:

I was not so much concerned about returning to work as I do sit most of the day in a sales office. However, I was greatly concerned if I could take the commute to work. Standing or sitting on the train during rush hour terrified me. I went for a prolonged stage recovery and finally returned to a limited schedule 16 weeks out.

These people are in our office because they are looking for options to accelerate the stability of their knees. They are in our office because of prolonged recovery time and a need to get back to work.

Now before you think, “this won’t happen to me,” or “these are isolated examples”, understand that there is mounting evidence from leading medical research universities and hospitals suggesting that returning to work after knee replacement is a much larger problem. Also understand that compared to the amount of research on knee replacement procedures, outcomes, and failure protocols, there is only a small amount of research information focused on giving doctors helpful information to offer knee replacement patients in helping them back to work. In fact, the most recent studies on this subject are focused on the lack of research and the lack of support in helping workers get back to the job. Here is the dilemma according to researchers:

15 to 30% of patients do not return to work after knee replacement

A study by a team of Canadian doctors published in the Annals of Physical and Rehabilitation Medicine (1) made this assessment:

“Total knee arthroplasty (replacement) is an effective intervention for people with osteoarthritis. However, 15 to 30% of patients do not return to work, and studies frequently fail to provide an explanation of what may lead to work disability. . . “

Now what is being said here is that researchers are looking at numbers and not reasons why people do not return to work. It may be a good idea to talk to patients who did not return to work as this may help other patients understand the challenges that the people who did not return to work could not overcome.

Identifying when patients return to work and if they return to normal hours and duties, and identifying which factors influence postoperative return to work.

In January 2019, researchers in Australia published these findings in the Journal of Orthopaedics and Traumatology (2) which told of the challenges patients faced in returning to work and why they did not.

Here are their observations and learning points:

• A substantial proportion of patients undergoing (knee replacement) are of working age.
• This study aimed to identify when patients return to work and if they return to normal hours and duties, and to identify which factors influence postoperative return to work.

The researchers looked at patients who had a total knee replacement, or medial unicompartmental knee replacement between 2015 to 2017.

• Patients returned to work an average of 7.7 weeks ( total knee replacement), and 5.9 weeks (medial unicompartmental knee replacement).

Here are the findings that the researchers stressed:

• There was a non-significant correlation between physical demands of the work versus time of return to work
• There was a significantly earlier time of return to work if flexible working conditions were resumed.
• Active recovery, motivation, necessity, and job flexibility enabled a return to work.
• The physical effects of surgery, medical restrictions, and work factors impeded return to work.

CONCLUSION: Rehabilitation, desire, and necessity promoted return to work. Pain, fatigue, and medical restrictions impeded return to work.

So what we have here are patients eager to return to work after knee replacement, and as we have seen, mostly out of desire or necessity to get back to work. What were the roadblocks to a successful return to work?

• Pain
• fatigue and
• medical restrictions

What helped the 70-80% of total knee replacement patients return to work within three to six months?

A 2021 study (8) from the  University of Amsterdam wanted to assess what helped the 70-80% of total knee replacement patients return to work within three to six months. These patients were asked:

• What was beneficial for return to work after total knee replacement
• What was limiting for return to work after a total knee replacement; and
• What additional care would benefit returning to work after total knee replacement?

Four main items contributed to a successful return to work:

• Rehabilitation (medical) like post-operative physical therapy.
• Patient characteristics (the personal desire) like motivation to return to work.
• Occupational characteristics (work-related accommodations) like build-up in work tasks
• and Medical support (medical) like the availability of a walker or crutches.

Many patients decided on retirement rather than go back to work after a total knee replacement

As we have seen in the previous study and patient observations, fatigue, pain, setbacks, and other medical problems may cause the person to simply seek early retirement. If you talk to a knee replacement patient who took this option, it may have been unlikely that they would have gone through with the surgery if they were going to retire

In a study of 167 patients who were working at the time of their total knee replacement surgery, researchers at the University of Amsterdam wanted to know why 46 patients did not return to work and 121 did. So they started looking for clues. (3)

• The average age of the 167 patients was 60 at the time of the surgery
• More than half of these patients had significant weight problems, 58% being obese
• Physically demanding work:
  • About half the patients: Forty-eight percent performed light work
  • 32 % medium-level physical work
  • and 20 % heavy knee-demanding work before total knee replacement surgery.
• Thirty-one percent of the total knee replacement patients were of the opinion that their work had caused or aggravated their knee symptoms.

Of the 46 that did not return to work:

• Eight of the patients said they did not return to work because of problems related to knee replacement.
• Seven of the patients reported other physical complaints that prevented them from returning to work.
• The other 31 took early retirement from this work.

The researchers noted something interesting in this group.

Before the surgery, these patients took a lot of days off or “sick leave.” The researchers speculated that knee pain was keeping them from work and that if they had knee replacement sooner they could have returned to work as opposed to “early retirement” or other problems related to their ability to do their job. As we have seen in our clinic, going for knee replacement sooner is not always a viable option, that is why the patient is in our office seeking an alternative to the knee replacement.

How about the 121 who did return to work:

• 8 returned to work within 1 month
• 50 between 1 and 3 months
• 43 within 3–6 months
• and 20 after 6 months.

Of these patients,

• 19 reported that they had a less physically demanding job after returning to work,
• 79 had an equally physically demanding job,
• and 12 had a more physically demanding job after returning to work.
• Regarding working hours, 11 patients reported fewer working hours, 96 reported the same number of working hours, and five reported more working hours.

The ability to make a living

The researchers made an interesting statement in their conclusion: “Total knee replacement surgery is being performed on an increasingly younger population of knee osteoarthritis patients for whom participating in work is of critical importance. . . .clinicians should be aware that proxies for participating in work go beyond outcomes like pain or function.”

In other words, patients will go back to work, if they can, regardless of pain and function improvements. We find that for many patients we see, it is the ability to make a living. They have to work.

Returning to work after knee replacement – getting the realistic assessment

Doctors in the United Kingdom examined the return to work experience in patients who had knee replacement surgery. Their study findings published in the British Medical Journal (4) surrounded the asking of 7 questions to patients POST-knee replacement.

1. Could you start explaining to me what your job involves?
2. How did your arthritis affect you/your work?
3. What happened since your operation?
4. Was the experience after the operation what you were expecting?
5. What was the involvement of your employer?
6. Is there anything that has helped you/ or would have helped you to return to work more easily?
7. What influenced the decision to return to work at that time?

Research: Three out of ten patients do not expect knee replacement to help them perform their job better

Here is a study led by the University of Amsterdam published in December 2018 in the Journal of Occupational Rehabilitation. (5) The question is asked:

• “What are patients’ expectations regarding the ability to perform work-related knee-demanding activities 6 months after (total knee replacement) compared to their preoperative status?”

The learning points:

• “Three out of ten patients do not return to work after total knee replacement. Patient expectations are suggested to play a key role.
• A study was performed among 236 working patients listed for total knee replacement.
• “A clinical improvement in the ability to perform work-related knee-demanding activities was expected by 72% of the patients, while 28% of the patients expected no clinical improvement or even worse ability to perform work-related knee-demanding activities 6 months after (total knee replacement.)
• Of the patients,
  • 34% expected severe difficulty in kneeling,
  • 30% in crouching and
  • 17% in clambering (climbing to reach something) 6 months after total knee replacement.
• Conclusions Most patients have high expectations, especially regarding activities involving deep knee flexion (bending). Remarkably, three out of ten patients expect no clinical improvement or even a worse ability to perform work-related knee-demanding activities 6 months postoperatively compared to their preoperative status. Therefore, addressing patients’ expectations seems useful in order to assure realistic expectations regarding work activities.

Positive outlook helps knee replacement recovery

However, a June 2022 study from  Kent State University researchers, published in the Journal of behavioral medicine (9) suggested that reliance factors such as self-belief in recovery, positive affect, vigor, and vitality may help against chronic pain pre and post knee replacement and assist in recovery.  In this study, 110 patients undergoing unilateral, total knee replacement surgery completed self-report assessments of study variables.

• Self-efficacy (a belief in their ability to heal and resume normal activities) was assessed two-one-half weeks prior to surgery, positive affect the day after surgery, vitality and vigor one-month following surgery, and post-operative pain at one- and three-months following surgery.
• Control variables included gender, pain, and depressive symptoms prior to surgery.
• Path analysis revealed significant self-efficacy benefits from pre-operative self-efficacy to positive affect during hospitalization, as well as to vitality and vigor at one-month following surgery.
• Both indicators of energy predicted better post-operative recovery (one-month: vitality  vigor); three-months: vitality vigor.

A big problem: post knee replacement information and rehabilitation centers for the retired.

Patients desiring help and information to return to work were not routinely discussed.

• The patients in this study found that the advice they received from healthcare professionals focused on the needs of the elderly and retired population.
• Preoperative education reportedly focused on the inpatient stay and immediate postoperative period, but longer-term outcomes, such as return to work, were not routinely discussed.
• In summary: Patients found that work-related activities were not discussed and focused on people of a certain age and people who didn’t work.

Patients are concerned that doctors do not factor in the patient’s ability to make a living in surgery decisions

In other words, the question of when can I return to work was not satisfactorily addressed for many. Some patients went to work when they felt like they needed to, and some stayed out of work waiting for doctor’s clearance.

• Doctors’ top priority in recommending knee replacement: Pain and Function
• Patients to priority: Function and get back to work

Researchers writing in the Medical Journal of Australia, (6) wanted to know what influenced surgeons in determining the order in which patients are scheduled for surgery. In their study, they asked a group of surgeons to assess the patient profiles of 80 patients. They also asked a group of non-medical personnel (lay people) to assess the patient profiles for their “lay” recommendation.

• Both groups determined that the patient’s pain was the number one concern.
• For the surgeons, the other determining factors were physical limitations and other medical factors.
• The laypeople saw it a little differently. While agreeing on the physical limitation part, they were concerned with the patient’s socio-economic situation and the stress a prolonged wait would bring on the patient’s ability to make a living as well as the psychological distress that may bring.

While the surgeons did not consider socio-economic factors in determining priority in patients’ wait time for surgery, it is clear that for the layperson, the delay to surgery, the surgery, and the recovery time from a total knee replacement are important factors.

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 which provides stability for the knee. This treatment does not address the problems of hardware malalignment. 

The inability to work is related to knee pain and knee instability, the feeling that the knee will give out or not support the entire body.

Summary of this video:

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.

Dr. Hauser performs an ultrasound scan of the patient’s knee. Small, gentle stress on the knee reveals hypermobility. This is from the ligaments’ inability to hold the whole knee joint in place. Prolotherapy can be very successful in helping patients who had a knee replacement and still have knee pain. The treatment tightens the whole joint capsule.

There is little in the literature to guide clinicians in advising patients regarding their return to work following a primary total knee replacement

One of the reasons the surgeons may not have prioritized this factor may be found in the literature. Researchers at the Case Western Reserve University School of Medicine. in their study published in the Journal of Joint and Bone Surgery, wrote:

“There is little in the literature to guide clinicians in advising patients regarding their return to work following a primary total knee (replacement). (This study) aimed to identify which factors are important in estimating a patient’s time to return to work…how long patients can anticipate being off from work, and the types of jobs to which patients are able to return following primary total knee arthroplasty.”(7)

Information for patients to assess from the study scores were:

• The average time to return to work after the surgery was nine weeks.
• Patients who reported a sense of urgency about returning to work were found to return in half the time taken by other employees
• Other preoperative factors associated with a faster return to work included being female, self-employment, higher mental health scores, higher physical function scores, higher functional comorbidity, and a handicap accessible workplace.
• A slower return to work was associated with having less pain preoperatively, having a more physically demanding job, and receiving Workers’ Compensation

Information for patients to assess from the study scores were:

• The average time to return to work after the surgery was nine weeks.
• Patients who reported a sense of urgency about returning to work were found to return in half the time taken by other employees
• Other preoperative factors associated with a faster return to work included being female, self-employment, higher mental health scores, higher physical function scores, higher functional comorbidity, and a handicap accessible workplace.
• A slower return to work was associated with having less pain preoperatively, having a more physically demanding job, and receiving Workers’ Compensation.

If you are on this page because you are seeking alternatives to knee replacement, let’s continue on with these articles on your options:

• The stem cell alternative to knee replacement:
  • Can you repair a bone on a bone knee without stem cell therapy?
• The platelet-rich plasma alternative to knee replacement: 
  • Platelet Rich Plasma Therapy for Knee Osteoarthritis
• The Prolotherapy alternative  to knee replacement please review this article: 
  • Prolotherapy Injections when the recommendation is Knee Replacement

If you have questions about knee replacement options ask us

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This article was updated June 5, 2022

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