Effects of Symmetry-Targeted Rehabilitation after Total Knee Arthroplasty: A Systematic Review

Abstract

Persistent inter-limb loading asymmetry and compensatory movement patterns may remain after total knee arthroplasty (TKA) despite improvements in pain and conventional functional outcomes. Symmetry-targeted rehabilitation has been proposed to specifically address these residual deficits. To systematically evaluate the effects of symmetry-targeted rehabilitation and movement retraining after unilateral TKA on limb-loading symmetry, gait and functional mobility, muscle strength, and patient-reported outcomes. PubMed, Cochrane Library, and ScienceDirect were systematically searched from January 2010 to September 2026. Comparative studies evaluating rehabilitation explicitly targeting movement or loading symmetry after unilateral TKA were included. Risk of bias was assessed using RoB 2 for randomized trials and ROBINS-I for non-randomized studies. Findings were synthesized qualitatively. Of 329 records identified, 322 were excluded during title and abstract screening, and five studies involving 266 participants were included. Symmetry-targeted interventions included force-based biofeedback, balance-board training, therapist cueing, and wearable insole feedback. Improvements in direct weight-bearing symmetry were inconsistent. Some studies demonstrated improved knee-joint mechanics, greater operated-limb utilization, reduced contralateral compensation, or improved sit-to-stand performance, while most gait, strength, and patient-reported outcomes were comparable with conventional rehabilitation. Symmetry-targeted rehabilitation may be a useful adjunct after unilateral TKA, particularly for patients with persistent movement asymmetry, but current evidence does not demonstrate consistent superiority over conventional rehabilitation.