I discovered I had osteoarthritis in both knees in early 2015. I found strength training very helpful and I took up powerlifting, competing at national level from 2017 to 2021 in the 60-64 then 65-69 year age category. I had a total knee replacement (TKR) of the left knee in March 2022.
Before doing the TKR, I spoke to my surgeon about what I would still be able to do with a TKR and also searched the web for information. My surgeon echoed the standard advice that high impact activities such as running and jumping should be avoided completely, as should activities that involve aggressive pivoting (tennis, basketball, most martial arts). A few specifically mention Olympic weightlifting as involving high impact and should be avoided (for example here). Even so, I have come across people who have continued to run or do martial arts after joint replacement.
Skiing is sometimes mentioned as an activity that is feasible after joint replacement, though often with the caveat “only if you are already an experienced skier”. My doctor made a point of saying that I would be fine to ski again, once he knew that I was an experienced downhill skier. I was particularly interested in whether I would be able to continue strength training, powerlifting in particular, after joint replacement. My surgeon said flat out I should not try to lift heavy weights after joint replacement and the internet search I did found only a handful of examples of people who had done so. But I found lots of advice from doctors and physios to avoid any heavy lifting. Some of this was clearly nonsensical. For example, here is advice from an orthopedic and sport medicine centre in 2019: “You’ll need to mind your artificial knee for the rest of your life. Avoid lifting anything more than 20 pounds.” Or another physiotherapist who advised to never deadlift after joint replacement.
A world record squat of 525 kg nine years after TKR
The most startling example of powerlifting after TKR I came across was Vlad Alhazov. He is a Russian-born powerlifter who set a world record for equipped squat (multi-ply) in 2008, squatting 567 kg (1250 lb). However, the following year while attempting 590 kg, his left knee caved resulting in his needing a full knee replacement. Nearly a decade later, he returned to powerlifting, this time raw (unequipped) and in 2018 set a world record for squat (with knee wraps) of 525 kg. His squats can be seen here. His best deadlift is 375 kg, limited by grip strength. With straps he has lifted 442.5 kg. But this man is clearly not only crazy, but a freak of nature. So his experience may well be a very unusual outlier.
The other thing I discovered from my searches is that there are almost no long-term studies of outcome for people who do continue participate in “strenuous sports” or high impact activities such as running. TKR tends to be done predominantly in older people and very few older people do serious strength training. I was unable to find any follow-up studies at all for strength training, let alone long-term ones. So, it’s possible that the usual medical advice is not evidence-based and coming from a lack of understanding or experience with strength training. After all, advice from health professionals with no experience of strength training is often of the form “squats are bad for the knees” and “deadlifts are dangerous for the back”.
My total knee replacement
I went ahead with TKR of the left knee in March 2022. My strength training helped me recover relatively rapidly and I worked hard with a physiotherapist over the next two months to recover full function and range of motion of the knee. In particular, the physio got me doing various forms of scaled bodyweight squats, including single leg squats that were quite intense. I decided that there was no reason I could not start squatting with light weights to a bench (for safety if I lost balance or control of the bar).
On the day the photo above was taken, I started barbell training again, doing 3×5 box squats with the empty bar (20 kg) to somewhat above parallel (touching the bench). A week later I was squatting 3×5 at 60 kg somewhat above parallel. Two months after surgery, I also started doing Romanian deadlifts, initially 50 kg for 8 reps, increasing to 75 kg for 3×8 at three months.
I was somewhat concerned about the potential for damage to the stability of the prosthesis or wear on the polyethylene cartilage replacement and decided to do a more systemic search for evidence and for examples of people doing strength training after TKR.
An unsystematic search for examples of strength training after TKR
The currently common advice is very conservative (understandably) and not based on evidence. The first step toward overturning an excessively conservative recommendation generally involves uncontrolled observational studies. If researchers observe that an allegedly dangerous behavior doesn’t appear to result in the predicted bad outcomes, it is a first step towards controlled cohort studies of the behaviour.
Using google searches and social media searches I found 13 examples of deadlifts and 15 of squats after joint replacement, with some information on the weight lifted and on the lifter. The majority of these examples were TKR of one knee. For the deadlifts, there was one hip replacement, one TKR+hip, two double TKR and one double TKR+hip. For the squats, there were two hip replacements, one TKR+hip and three double TKRs.
The table below summarizes the data for these lifters.
The figures in red were missing and estimated either from appearance (for bodyweight and age) or based on averages for the non-missing data. Where the weight lifted was for multiple reps, I estimated the 1 rep max (1RM) using an online calculator, and ignored the fact that true maxes may be higher than the numbers reported. Sources for the data are listed at the end of this blog post.
It is important to emphasise that these data in no way are a representative sample of people’s experience after TKR. People who self-post videos and results to the internet are more likely to be people who have been training seriously before and after joint replacement, and people who are lifting heavy weights and want to post about their progress. For almost all the examples, there is data for a single time point only and the pattern of results cannot be interpreted as providing any information about rate of progress with time after joint replacement.
With those caveats, I did of course plot the results to get some sense of them. To do so, I converted all the results to 1 rep max results, and then adjusted them using Wilks weights for bodyweight and McCulloch weights for age, so that the adjusted 1 rep maxes relate to a 50-year-old person with bodyweight 85 kg. Also, for the sake of comparability, I plotted males only (there was only one woman in the dataset) and excluded Vlad Alhazov (apart from being an outlier, he was the only data point with more than 3 years since surgery).
Here are the results for males excluding Vlad, with of course linear trend lines that should absolutely not be interpreted as saying anything about progress with time since surgery.
I was surprised to see a couple of men who were lifting moderately heavy weights within a month or two of surgery, and also just how heavy on average the weights lifted were. The median adjusted 1RM (for 85 kg 50 year old) were 157 kg for deadlift and 155 kg for squat. Of course, this is almost certainly due to self-selection of experienced lifters who thought their results would be of interest to others.
I am one of the data points. Five months after my left TKR, I also had a replacement of the right hip, so my data is for TKR + hip. Twelve months after the TKR and 7 months after the hip replacement, I deadlifted 150 kg and squat 120 kg (above parallel) at age 70.
Views are changing on strength training after joint replacement
In my recent internet searches, I came across a number of research papers reporting medium term follow-up studies for people who had continued to run or participate in various sports and found that their outcomes were no worse than those who were not doing those activities. I also found several medical and physiotherapy websites that explicitly recommended resistance training after joint replacement. Part 2 of this post will look more closely at these recent studies and at data on joint replacement failure. In the meantime, I will conclude this post with a couple of quotes:
According to Beacon Orthopedics and Sports Medicine:
“Patients are often most surprised to learn that they are not only permitted to lift weights but are encouraged to lift weights after receiving a joint replacement. In fact, lifting weights is the best thing a patient can do for the prolonged life of their artificial joint.
“When done with proper form, weight lifting—also called resistance training—strengthens muscles and increases bone density, all while being relatively easy on the joints. With that said, improper form can severely damage joints, so it is imperative that you use proper form to ensure the longevity of your artificial joint.”
Dr Luke Peterson, knee replacement physical therapist, explains that strength training has huge benefits, resulting in more knee stability and bone density and firmness of knee implant in bone. It is important to use good technique, slow progression and start low intensity and build up slowly.
Kevin Stone, orthopaedic surgeon, writing in 2015, said that “After your knee replacement, our advice is to exercise more than you have in years. Focus on total body muscle building and weight optimization. You can likely return to most sports when you are fit enough to protect your joints.”
If you would like to contribute to my unsystematic dataset, please make a comment with some information on your age, weight, surgery, and time since surgery, as well as 1 rep max for squat or deadlift.
3. Matt Vincent. https://www.youtube.com/watch?v=WLHuwD_4c2Y
4. Shelley Kresan. https://www.youtube.com/watch?v=VuiOXkq5nn4&t=583s
4. Shelley Kresan. https://www.youtube.com/watch?v=VuiOXkq5nn4&t=583s
6. James Burnett. https://www.youtube.com/watch?v=VuiOXkq5nn4&t=583s
7. Colin Mathers. Blog post
8. Cameron Bucek. https://games.crossfit.com/athlete/225539
11. Vlad Alhazov . https://www.youtube.com/watch?v=MzOXefrlWYM
15. Rob Schmidt. https://youtu.be/dtozQJ6A5Is
17. Michael Clark. https://www.elitefts.com/training-logs/total-knee-replacement-required/