PURPOSE: This systematic review evaluated the efficacy of postoperative rehabilitation for patients at risk of poorer outcomes after total knee arthroplasty. METHODS: Six databases were searched, and only randomised controlled trials were included. Two reviewers independently screened, extracted data, and appraised the quality of the studies. RESULTS: Twenty-three studies were included. Insufficient evidence supports cognitive behavioural therapy for patients with kinesiophobia, while continuous passive motion may not be effective for range of motion deficits. The impact of exercise therapy on functional recovery is conflicting; however, longer durations tend to be more effective for older patients and those with functional limitations. Limited evidence suggests that exercise may not alleviate pain. Outpatient exercise therapy improves health-related quality of life more than home-based programs for older patients and those with functional limitations. The efficacy of other rehabilitation aspects remains inconclusive due to high heterogeneity in interventions and outcome measures, and high or unclear risk of bias in most studies. CONCLUSION: While limited evidence suggests benefits for specific rehabilitation interventions, there is insufficient data to assess the efficacy of most interventions on postoperative recovery in those at risk of poorer outcomes. More robust evidence is needed to guide clinical practice and standardise outcome measures. TRAIL REGISTRATION: PROSPERO CRD42022355574.