Rehabilitation Protocols
Phase-by-phase, criteria-based pathways after knee and ankle surgery or injury. Written on two levels: plain guidance for families and objective criteria for physiotherapists.
These documents are protocol templates for information and education only: they do not replace the rehabilitation prescription for the individual case. Timing, loading and progressions must always be adapted to the patient, the lesion pattern, the surgical technique used and the clinical course, in collaboration between orthopaedic surgeon, physiotherapist and, where appropriate, physiatrist. Progression is driven by objective criteria, not by the calendar alone.
Knee
Protocols after ligament reconstruction and meniscal surgery, including physeal-sparing techniques in the growing patient.
Anterior Cruciate Ligament (ACL) Reconstruction
Five-phase pathway after ACL reconstruction in the skeletally mature patient: from early post-operative recovery to return to team, with objective criteria between phases.
Return to pivoting sport: not before 9 months, typically 9-12 monthsPaediatric ACL reconstruction (all-epiphyseal / all-inside)
Protocol for the patient with open growth plates operated with physeal-sparing techniques: more cautious progressions, growth surveillance and later return to sport.
Return to sport: typically 10-12 months, with growth surveillance at 6-12-24 monthsACL reconstruction with meniscal repair
Combined protocol: on top of the ACL progression sit the loading, deep-flexion and rotation restrictions required for healing of the repaired meniscus.
Typically 4-8 weeks longer than isolated ACL; return to sport at 9-12 monthsIsolated meniscal repair
Protocol modulated on tear pattern (PAASS framework): freer loading and ROM in peripheral longitudinal tears, more protected in radial, complex and root tears.
Return to sport: 4-6 months, criteria-drivenMPFL reconstruction after patellar dislocation
Pathway after medial patellofemoral ligament reconstruction: early graft protection, recovery of quadriceps control and dynamic valgus control, return to sport without apprehension.
Return to sport: typically 6-9 monthsKnee Osteochondral Lesion: fragment fixation or microfracture
Six-phase pathway after treatment of an osteochondral lesion of the femoral condyle or patella, detailing the substantial differences between fragment fixation (native hyaline cartilage is preserved) and microfracture (reparative fibrocartilage is formed).
Protected weight bearing 6-8 weeks · Running 4-6 months · Contact/pivoting sport 9-12 months (fixation) or 8-12 months (microfracture)Tibial Spine (Eminence) Fracture: reduction and fixation with bioabsorbable pins
Five-phase protocol after reduction and fixation of a tibial eminence fracture with bioabsorbable pins (Smart Nails), screws or suture: the paediatric equivalent of an ACL injury, except that here bone heals, not ligament.
Immobilisation in extension 30 days · Non-weight bearing 30 days · Full weight bearing 6-8 weeks · Running 3-4 months · Pivoting sport 6-9 monthsAnkle
Conservative pathways with objective return-to-sport criteria and prevention of chronic instability.
Ankle sprain: conservative protocol
Conservative pathway based on early protected loading, peroneal strengthening and proprioceptive retraining, with objective return-to-sport criteria and prevention of chronic instability.
Return to sport: 2-8 weeks for grades I-II, longer for grade III and syndesmotic injuriesOsteochondral Lesion of the Talus: fragment fixation or microfracture
Five-phase protocol after treatment of an osteochondral lesion of the talar dome, comparing fragment fixation with microfracture/nanofracture and managing loading in the joint that carries more weight per square centimetre than any other.
Non-weight bearing 6 weeks · Full weight bearing 8-10 weeks · Running 4-6 months · Sport 6-12 monthsFoot
Post-operative pathways after paediatric foot surgery, centred on early active and passive mobilisation.
Flatfoot: post-operative pathway after endosinotarsal arthroereisis
Post-operative pathway after arthroereisis with the screw housed in the sinus tarsi, without a cast: limited weight bearing in the first 72 hours and active and passive mobilisation without resistance from day 1.
Active and passive mobilisation from post-op day 1 · Limited weight bearing for 72 hours, then 2 crutches · Crutches stopped at suture removal (~2 weeks) · Running from day 45 · Sport at 2 monthsFlatfoot: post-operative pathway after exosinotarsal arthroereisis
Post-operative pathway after arthroereisis with a screw passing through the calcaneus, without a cast: assisted weight bearing with crutches from discharge and active and passive mobilisation without resistance from day 1.
Active and passive mobilisation from post-op day 1 · Walking with 2 crutches from discharge · Crutches stopped at suture removal (~2 weeks) · Running from day 45 · Sport at 2 monthsFlatfoot: post-operative pathway after arthroereisis with Achilles lengthening
Post-operative pathway when arthroereisis is combined with Achilles tendon lengthening for triceps surae shortening: below-knee cast for about 30 days, then intensive recovery of range and push-off strength.
Below-knee cast ~30 days with weight bearing on a cast shoe · Full ankle mobilisation from cast removal · Night splint for a further 30 days · Running from month 2 · Sport at 2-3 monthsFlatfoot: post-operative pathway after arthroereisis with accessory navicular excision
Post-operative pathway when arthroereisis is combined with excision of a painful accessory navicular: short cast of about 15 days, then intensive mobilisation and medial scar care.
Cast ~15 days with weight bearing on a cast shoe · Full mobilisation from cast and suture removal · Running from day 45 · Sport at 2 months
Any questions?
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Email: daniele.priano@ortopediaevolutiva.com