Companion to the Arthroplasty Quick Reference (perioperative pathway) and the patient knee replacement guides. Terminology matches what patients are taught in those guides.
Philosophy
The Quiet Knee approach prioritizes controlling swelling and inflammation first. A calm, non-inflamed knee lets the quadriceps fire again (less arthrogenic muscle inhibition), so motion returns with less pain and less opioid use. Aggressive early forced flexion and painful hands-on therapy are avoided; strengthening is layered in once the knee is quiet (~week 4). In HSS data, this approach lowered opioid exposure and shortened length of stay versus traditional aggressive rehab, without added risk or loss of motion.
What the Patient Arrives With
- Adductor canal block + periarticular injection — quad-sparing by design, but the leg may feel stronger than it is as the block recedes. This is the highest fall-risk window; patients are taught to use the walker every single time.
- Waterproof antimicrobial (silver) dressing, left undisturbed 5–7 days — showering with it on from POD 1 is expected. Sutures/staples out at the ~2-week visit.
- Scheduled multimodal analgesia: dexamethasone 16 mg PO on POD 1; celecoxib 200 mg BID (patients may substitute OTC naproxen or ibuprofen); acetaminophen 1,000 mg q8h × 2 weeks; opioids rescue only. Encourage pre-medication before sessions in the early weeks.
- Aspirin 81 mg BID × 2 weeks for VTE prophylaxis (a DOAC instead if elevated-risk). Mobilized the day of surgery; most patients discharge same-day or after one night.
Phase 1 · Weeks 0–2 — Calm the Knee
- Priority: aggressive swelling control — frequent cryotherapy, elevation above the heart, and compression.
- Protect the knee; gentle, restricted activity. Weight-bearing as tolerated with a walker or crutches.
- Gentle passive and active-assisted ROM as tolerated — do not force flexion.
- Emphasize full extension (heel props, prone hangs). Patients are told never to prop a pillow under the knee — reinforce this.
- Quadriceps activation: quad sets, straight-leg raises, ankle pumps.
- Avoid aggressive, painful therapy or manipulation.
Phase 2 · Weeks 2–4 — Restore Motion Calmly
- Continue swelling control (ice, elevation, compression).
- Progress ROM gently as swelling allows — flexion advances naturally as the knee quiets; still avoid forced end-range pushing.
- Normalize gait; wean the assistive device as quad control and gait allow.
- Continue quad activation and maintain full extension.
Phase 3 · Weeks 4–8 — Add Strengthening
- Once the knee is quiet (minimal effusion, good quad control): begin progressive strengthening — closed-chain mini-squats, step-ups/downs, leg press in a comfortable range, plus hip and core work; stationary bike.
- Continue advancing ROM toward full; add balance and proprioception.
- If effusion flares, back off loading a step until the knee settles.
Phase 4 · Weeks 8+ — Function & Return
- Progressive strengthening and endurance; functional and low-impact activity; return to activities as tolerated.
- Goals: full functional ROM, symmetric quadriceps strength, and normal gait and stair mechanics.
Notes
- Persistent or increasing effusion is the signal to reduce loading — swelling control remains the priority throughout.
- The quiet approach typically reaches functional ROM without forcing; manipulation under anesthesia is rarely needed. Individualize to the patient.
References
HSS Research: the "Quiet Knee" Protocol for total knee replacement recovery. Hospital for Special Surgery, 2025.
Quiet Knee Rehabilitation Protocol After Primary Total Knee Arthroplasty Is Associated With Lower Opioid Exposure and No Added Risks: A Retrospective Cohort Study. J Arthroplasty, 2025.