Persistent Pain Management & Knee Replacements:

Living With Persistent Pain and How Physiotherapy Can Help

Knee replacement surgery can be life-changing for people with severe knee osteoarthritis, relieving pain and improving mobility when other treatments have not been effective. However, for some Australians, significant pain may persist even after surgery, or chronic knee pain may limit function before surgery occurs. Persistent pain does not necessarily indicate that the surgery has failed; rather, it reflects the complex nature of pain and highlights the important role physiotherapy can play in supporting recovery and long-term function.

What Is Persistent Pain?

Persistent pain, sometimes referred to as chronic pain, is pain that lasts longer than three months and does not always correspond directly to the degree of physical tissue damage. Pain is influenced by a combination of biological, psychological, and social factors rather than structural changes alone (Mills et al., 2019).

The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Raja et al., 2020, p. 1977). This definition highlights the role of the nervous system and the brain in the experience of pain. As a result, even after surgical procedures such as knee replacement, persistent pain may arise from increased nervous system sensitivity or learned protective responses rather than ongoing tissue damage.

Persistent Pain After Knee Replacement

Total knee replacement (TKR) is considered an effective treatment for advanced osteoarthritis, yet some patients continue to experience ongoing pain following surgery. Research suggests that approximately 15–20% of patients report moderate to severe long-term pain after knee or hip replacement surgery (Beswick et al., 2012).

Persistent post-surgical pain may be influenced by several factors, including:

These factors highlight that successful recovery involves more than addressing joint structure alone and emphasise the importance of rehabilitation and pain education.

Australian Clinical Guidance: First-Line Management

In Australia, best-practice management of knee osteoarthritis and persistent joint pain is guided by evidence-based clinical standards. The Australian Commission on Safety and Quality in Health Care (ACSQHC) recommends that core treatments for osteoarthritis include patient education, exercise therapy, weight management where appropriate, and support for self-management (Australian Commission on Safety and Quality in Health Care, 2024).

These conservative management strategies should be optimised before surgical intervention is considered and remain important components of rehabilitation following knee replacement. The ACSQHC clinical care standard also emphasises that imaging and surgical referral should occur only after appropriate non-surgical treatments, including physiotherapy, have been explored (ACSQHC, 2024).

How Physiotherapy Can Help

Education About Pain and Recovery

Physiotherapists help individuals understand that pain does not always reflect structural damage and that gradual movement and rehabilitation are safe and beneficial. Improving a person’s understanding of pain can reduce fear of movement and improve participation in rehabilitation (Mills et al., 2019).

Education is also recognised as a core component of high-quality osteoarthritis care within Australian clinical guidelines (ACSQHC, 2024).

Graded Exercise and Strength Training

Exercise is widely recognised as a cornerstone treatment for knee osteoarthritis and post-surgical rehabilitation. Land-based exercise programs, including strengthening and aerobic activity, have been shown to reduce pain and improve physical function (The Royal Australian College of General Practitioners, 2018).

Physiotherapists typically prescribe exercises that progressively increase strength and function. These programs often focus on strengthening the quadriceps, hip muscles, and core, which help support the knee joint and improve movement efficiency.

Following surgery, exercise programs begin with low-intensity movements and gradually progress as strength, confidence, and joint tolerance improve.

Movement Retraining and Functional Skills

Individuals who have experienced long-term knee pain often develop compensatory movement patterns designed to protect the painful joint. These altered patterns may persist even after surgery. Physiotherapy aims to retrain functional movements such as walking, stair climbing, and sit-to-stand transitions. Improving movement mechanics and balance helps redistribute joint loads and encourages safe, confident movement.

Pacing and Flare-Up Management

Persistent pain often fluctuates over time. Physiotherapists commonly teach pacing strategies to help patients manage periods of increased pain without avoiding activity altogether. Pacing may involve breaking tasks into manageable segments, adjusting activity intensity, and gradually building tolerance to movement.

A Multidisciplinary Approach

Physiotherapy is one component of a broader multidisciplinary approach to persistent pain management. Depending on individual needs, care may also involve general practitioners, orthopaedic surgeons, dietitians, or pain specialists. This collaborative approach addresses the physical, psychological, and social aspects of persistent pain.

Living Well With Persistent Pain

Persistent pain does not necessarily mean that recovery has failed or that improvement is impossible. Instead, it reflects the complex interaction between the body, nervous system, and lifestyle factors. Through education, graded exercise, movement retraining, and pacing strategies, physiotherapy can help individuals regain confidence in their knee, improve function, and participate more fully in everyday activities.

References

Australian Commission on Safety and Quality in Health Care. (2024). Osteoarthritis of the knee clinical care standard. https://www.safetyandquality.gov.au/publications-and-resources/resource-library/osteoarthritis-knee-clinical-care-standard-2024

Beswick, A. D., Wylde, V., Gooberman-Hill, R., Blom, A., & Dieppe, P. (2012). What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies. BMJ Open, 2(1), e000435. https://doi.org/10.1136/bmjopen-2011-000435

Mills, S. E. E., Nicolson, K. P., & Smith, B. H. (2019). Chronic pain: A review of its epidemiology and associated factors in population-based studies. British Journal of Anaesthesia, 123(2), e273–e283. https://doi.org/10.1016/j.bja.2019.03.023

Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., Keefe, F. J., Mogil, J. S., Ringkamp, M., Sluka, K. A., Song, X. J., Stevens, B., Sullivan, M. D., Tutelman, P. R., Ushida, T., & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: Concepts, challenges, and compromises. Pain, 161(9), 1976–1982. https://doi.org/10.1097/j.pain.0000000000001939

Royal Australian College of General Practitioners. (2018). Guideline for the management of knee and hip osteoarthritis (2nd ed.). https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/knee-and-hip-osteoarthritis