Efficacy of Pre-operative Physical Therapy on Total Knee Replacements: A Systematic Review of Randomized Controlled Trials

Abstract Purpose The purpose of the study was to determine whether pre-operative physical therapy improves post-operative outcomes in adults undergoing primary unilateral total knee arthroplasty (TKA) for osteoarthritis. Methods We conducted a systematic search of MEDLINE, CINAHL, EMbase, Cochrane CENTRAL, and Google Scholar. Eligible studies were randomized controlled trials including adults awaiting primary unilateral TKA that compared a structured pre-operative physical therapy program against usual care/no intervention, initiated ≥ 3 weeks pre-operatively, and reported ≥ 2 post-operative functional outcomes. Two reviewers extracted study characteristics, interventions, and outcomes. Methodological quality was appraised using the PEDro scale. Because of heterogeneity of interventions and outcome measures, a narrative synthesis was performed. Results Eleven randomized controlled trials met inclusion criteria with generally good methodological quality. Interventions commonly included lower-limb strengthening, with variable incorporation of balance/proprioception and aerobic warm-up. Across trials, pre-operative physical therapy demonstrated small-to-moderate advantages for early post-operative pain and function (e.g., WOMAC subscales) and for selected performance tests (e.g., timed up and go), while effects on range of motion and length of stay were minimal or inconsistent. Higher-intensity resistance training and programs including proprioceptive work tended to yield more favorable early outcomes. Robust between-group differences at ≥ 6–12 months were uncommon. Discussion Pre-operative physical therapy may confer modest, clinically relevant improvements in early pain, function, and selected performance outcomes after TKA, particularly when programs emphasize progressive strengthening and proprioceptive/balance training. Evidence remains heterogeneous, and durable long-term benefits are uncertain. Standardized, adequately powered trials using common outcome sets and evidence-based dosing are needed.