Do we need rehabilitation after total knee arthroplasty? Evidence, uncertainty and the need for focus

The global increase in total knee arthroplasty has led to greater examination of postoperative recovery, particularly the effectiveness and purpose of rehabilitation. Although surgery reliably reduces pain and improves patient-reported assessments of function, objectively measured physical activity commonly declines after surgery and often remains below preoperative levels for prolonged periods. This mismatch exposes shortcomings in traditional outcome measures and challenges longstanding assumptions about predictable, linear recovery. Emerging evidence from recent trials questions the clinical impact of conventional preoperative and postoperative rehabilitation programmes. At the same time, national registry data show that inadequate restoration of daily activity carries significant long-term socioeconomic consequences. These findings collectively indicate a need to move beyond protocol-driven models of rehabilitation towards a deeper understanding of the biological, behavioural and contextual factors that shape recovery. It proposes a conceptual shift towards personalised, dynamically reassessed recovery pathways informed by objective activity measurement, patient-centred outcomes and mechanistic understandings of postoperative physiology. The central question is not whether rehabilitation is required, but how to identify which individuals need targeted therapy, at what point in their recovery, and through which interventions. Reframing rehabilitation in this way is essential to closing the gap between symptomatic improvement and meaningful functional recovery after knee replacement surgery. Level of Evidence N/A, narrative commentary.