For physiotherapists: adapt exercises, dosage and progression to the injury or procedure, protection, permitted loading and movement; check clinical criteria, not elapsed time alone.
Scope and before starting
Physiotherapy framework after knee osteochondral surgery. Fixation, drilling/microfracture and condylar versus patellofemoral sites do not share the same restrictions. Grafts, cell-based repair and osteotomies require a specific plan.
Operation report and prescription
Record procedure, site/size, fixation stability and associated operations. Obtain prescribed weight bearing, range and brace settings before exercise.
Lesion site
Weight bearing for a condylar lesion and loaded flexion for a patellofemoral lesion need different limits: record them in the personal plan.
Progression
Motion, loading and impact require separate clearance; strength tests do not establish biological healing. Functional checks are a practical checklist adapted from the sources, not validated paediatric return-to-sport tests.
Perform only the exercises selected for you, at the prescribed dose. If permitted loading or movements are missing from your handout, ask for these to be completed before starting.
Do not try running or hopping to check whether you have healed.
Report pain or swelling that develops after the session too.
Treatment phases and illustrated exercises
Exercises are shown in their assigned starting phase, with their instructions and precautions. The physiotherapist selects them for the individual plan; the complete protocol is not a prescription to perform them all.
Respect the minimum times and protection required for the procedure. Time alone does not authorise progression: the treating team checks the clinical criteria.
Preparation for surgery (elective cases)
Short educational and functional phase in elective cases; not applicable to acute cases needing immediate treatment.
Goals
Practical crutch and off-loading training according to the planned post-operative weight bearing.
Effusion and pain control.
Maintenance of the allowed range of motion, without stressing the involved compartment.
Maintenance of strength in uninvolved regions (hip, core, contralateral limb).
Preparation plan
Crutch practice on level ground and stairs, with the prescribed weight bearing.
Education on off-loading times, use of any brace and return to school.
Precautions
Acute, salvageable osteochondral fragment: fixation must not be delayed.
Loose body with joint locking or recurrent effusion.
Criteria checked by the treating team
The patient uses crutches correctly with the planned weight bearing.
Pain and effusion controlled.
Allowed range of motion maintained.
Family informed about the planned procedure and post-operative restrictions.
When preparation is useful
Only in cases already selected for surgery, with a planned indication: not every stable lesion needs surgery, many are managed conservatively.
No aggressive prehabilitation: the aim is to arrive prepared, not trained.
The type of procedure (fragment fixation, microfracture/marrow stimulation or other techniques) changes post-operative restrictions: these are explained before surgery.
Home and school preparation
Organise movement at home: clear pathways, remove rugs, keep useful items within reach.
Prepare ice, a support for the heel, comfortable clothing and crutches already adjusted.
Inform school or the sports club: plan the absence, temporary exemption and gradual return.
Agree the first post-operative physiotherapy session in advance.
Crutch and weight-bearing training
Short educational and functional phase in elective cases; not applicable to acute cases needing immediate treatment.
Try the crutches before surgery, with correct height and the weight-bearing status set by the surgeon.
Practise on level ground, stairs and the entrance to your home, with someone assisting.
Also practise sitting, standing and moving in the bathroom while respecting the planned loading restrictions.
Dose and progression: At least one training session before admission; repeat until the technique is safe.
Quadriceps isometric contraction (quad set)
Short educational and functional phase in elective cases; not applicable to acute cases needing immediate treatment.
Lying down, knee straight in a neutral position on the surface; if proprioceptive feedback helps, place a small rolled towel under the knee.
Contract the quadriceps pushing the back of the knee toward the surface, hold, then release slowly.
Aim for a visible, global quadriceps contraction, without breath holding.
Dose and progression: Indicative: 10 contractions of 5 seconds, 2-3 times a day. To be adapted with the physiotherapist.
Bridge
Short educational and functional phase in elective cases; not applicable to acute cases needing immediate treatment.
Supine, knees bent and feet hip-width apart on the floor.
Lift the pelvis squeezing the glutes, without arching the back, then lower slowly.
Dose and progression: Indicative: 2-3 sets of 10-12 repetitions.
1. Initial protection
After surgery
Goals
Protect the procedure and control swelling.
Physiotherapy plan
Crutches and transfers within prescribed loading.
Static quadriceps contractions within the permitted range; straight-leg raise only without sagging and with the brace if prescribed.
Precautions
No loading or bending beyond written limits.
Criteria the treating team checks before progression
Instructions followed, wound and symptoms controlled.
Motion permitted.
Illustrated exercise options
Quadriceps isometric contraction (quad set)
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
Lie on your back with the leg supported and the knee within the authorised extension range.
Tighten the front of the thigh without lifting the leg or forcing the knee. Use a small support under the knee only if demonstrated by your physiotherapist.
Hold briefly and relax. Lifting the heel is neither a target nor proof of full extension.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Controlled straight-leg raise
When motion and muscle activation are permitted and you can keep the knee straight without it sagging; practise first with the physiotherapist.
Lie on your back, position the other leg within its permitted range and keep the exercising leg as instructed; if both sides are treated, respect each side’s limits.
Tighten the thigh and slightly lift the leg while keeping the knee straight; lower it slowly.
If the knee bends during the lift, return to a supported quadriceps contraction. No ankle weights; do not remove a brace without permission.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
2. Protected movement
During protection
Goals
Gradually regain permitted movement.
Physiotherapy plan
Gentle active/assisted motion; measure extension and flexion.
Maintain thigh and hip control without stressing the repair.
Precautions
Do not force a target angle or advance weight bearing.
Criteria the treating team checks before progression
Prescribed range obtained without a joint reaction.
Loading and strengthening cleared.
3. Walking and basic strength
After protection is reviewed
Goals
Restore gait and weight-bearing control.
Physiotherapy plan
Progress loading and reduce crutches without limping.
Progress from static control to dynamic thigh/hip strength: mini-squats within the permitted range, supported firm-ground balance, then single-leg balance if controlled; cycling if allowed.
Precautions
No impact; respect loaded-flexion limits.
Criteria the treating team checks before progression
Walking and exercise tolerated without reactive effusion.
Sufficient control for increased weight-bearing work.
Illustrated exercise options
Walking with crutches and prescribed foot contact
Only when some foot contact is permitted. The figure does not show a fully non-weight-bearing pattern: if contact is prohibited, you need specific instruction.
Have the crutches adjusted and learn the sequence appropriate to your loading limit from the physiotherapist.
Practise on a level, clear path with an adult nearby; the foot contacts the ground only as prescribed.
Stop if limping, pain or fatigue increase. Practise stairs with assistance; do not stop using crutches solely because pain decreases.
Dose and progression: Agreed short distances with rests; duration and frequency depend on prescribed loading and gait quality.
Wall-supported mini-squat
Only after clearance for full weight bearing and strengthening; use the range selected by the physiotherapist.
With your back against the wall as shown, place the feet slightly forward and keep within prescribed loading.
Slide down a short distance within the range set by the physiotherapist, with knees pointing in the same direction as the feet.
Return slowly. Do not copy the illustrated depth if it exceeds your prescribed limit.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Double-leg bridge
When knee flexion, foot contact and pushing through both feet are allowed. This is not a non-weight-bearing exercise.
Lie on your back with knees bent within the permitted range and feet supported.
Slowly lift the pelvis using the buttock muscles, without arching the back or aiming for extra height.
Lower with control. No single-leg bridge, pelvic weights or forefoot-only support without further instruction.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Firm-ground balance
After clearance for full weight bearing and single-leg support; practise first with the physiotherapist.
On firm ground with eyes open, slightly lift the other foot while keeping the pelvis level.
Keep one hand on a stable support as illustrated; an adult must be able to assist the child.
Put the free foot down before losing control. Do not add cushions, closed eyes or perturbations.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Easy stationary cycling
Only if the treating clinician permits cycling, pedal loading and the movement range. Cycling is not equivalent to complete offloading.
Use a stationary bike suited to your height; the physiotherapist adjusts the seat and supports for the permitted movement.
Pedal seated and slowly with minimal resistance; do not force a complete revolution if motion is still insufficient.
Do not stand on the pedals, sprint or increase duration and resistance together. Monitor pain, movement quality and swelling during the session and the next day. If they worsen, stop the activity that causes them and inform the team; absence of swelling alone does not authorise increasing the load.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
4. Advanced strength and control
Before impact
Goals
Prepare the limb for running demands.
Physiotherapy plan
Progress resistance and single-leg work: steps and squats within the cleared range.
Non-impact conditioning and assessment of strength/movement quality.
Precautions
Do not use maximal hopping to decide whether cartilage has healed.
Stop a new load that causes effusion and agree an adjustment with the team; recurrent or persistent swelling requires reassessment. Do not automatically try again after a few days.
Criteria the treating team checks before progression
Assess low steps and squats within the cleared range without buckling or compensation; record quadriceps force with a dynamometer if available and compare across reviews without universal cutoffs.
Healing/procedure reassessed and impact cleared by the surgeon.
Illustrated exercise options
Controlled low step-down
After recovering a controlled step-up and receiving clearance for single-leg eccentric work; walking clearance does not automatically permit it.
On a low step, stand on the treated leg and keep a hand on the rail as illustrated.
Slightly bend the knee and lower the free heel towards the floor without dropping down or twisting the pelvis.
Use the free foot and hand support to return as taught. Reduce height and range if movement control deteriorates.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
5. Running and hopping
Only after impact clearance
Goals
Restore tolerance of sporting movements.
Physiotherapy plan
Begin with interval straight-line running without joint reaction; then small hops with controlled landings, followed by deceleration and direction changes if control remains good.
Increase one parameter at a time and check the response after sessions.
Precautions
Stop progression for new swelling or joint pain.
Criteria the treating team checks before progression
Progressive tasks tolerated without a joint reaction.
Ready to resume training.
Illustrated exercise options
Straight-line walk–run progression
Only after running clearance under this protocol and assessment of motion, strength and control. Also respect the protection period for the injury or operation.
On level, even ground, alternate walking with short bouts of easy straight-line jogging according to the physiotherapist’s programme.
Keep an even gait without limping. Begin without sprinting, hills, jumping or direction changes.
Increase one demand at a time. If joint pain, limping or swelling occurs during the work or the next day, stop the progression and report it to the physiotherapist.
Dose and progression: Run/walk intervals, duration and recovery set by the physiotherapist for the procedure, age and response to loading; the phase does not provide an automatic dose.
Small two-foot forward hops
Only after jump clearance and an on-the-spot landing check by the physiotherapist. The figure shows the forward progression, to introduce with them.
With the physiotherapist, make one small two-foot forward hop on a firm, even surface, as illustrated.
Land on both feet with control and pause before repeating. The physiotherapist selects distance and number of hops; no sideways or single-leg hops without further instruction.
Stop for pain or loss of control and report pain or swelling afterwards.
Dose and progression: Initial attempts and dose selected by the physiotherapist; increase only after checking the subsequent response.
Planned braking and direction changes
After tolerating straight-line running and receiving specific clearance for braking and direction changes. First practise with the physiotherapist; this is not an initial running exercise.
With the physiotherapist, begin with controlled slowing and wide turns at low speed in agreed directions.
Control the trunk, knee and foot. Increase speed and turning angle separately; sharp, reactive or contact movements require further assessment.
Stop for pain, giving way or limping; also report swelling or pain after the session and the next day.
Dose and progression: Intervals, rests and recovery days selected for age, sport and previous level. No independent maximal tests; tolerate full training before competition.
6. Return to sport
After functional recovery and review
Goals
Tolerate full sporting demands.
Physiotherapy plan
Partial training, full training, then competition.
Maintain limb strength and control.
Precautions
No return based only on time elapsed.
Criteria the treating team checks at the end of the pathway
Full training tolerated.
Shared decision involving surgeon, physiotherapist and patient/family.
Return to sport / full activity
Both procedure-specific healing times and functional criteria must be respected.
Healing assessment and surgeon clearance.
Document quadriceps strength (dynamometer if available), steps and landing control only after impact clearance; compare over time without relying on symmetry alone.
Full training without pain, swelling or giving way.
Warning signs: stop and contact the treating team
Fever, increasing wound redness or warmth, or drainage: contact the surgical team the same day, even without fever.
Increasing pain, new locking, persistent swelling or loss of regained movement: stop progression and arrange reassessment.
A cold or pale foot, reduced sensation or severe pain under a cast/brace needs urgent assessment. Breathing difficulty or chest pain is an emergency.
Guidelines and literature
Sources inform the pathway; they do not validate every dose for an individual child.
A framework to personalise with the orthopaedic clinician and physiotherapist, not a replacement for an individual prescription. Respect protection and clinical criteria, not dates alone.
Select the exact phase assigned by the treating team, then choose each prescribed activity. No exercise is selected automatically. The team sets loading, movement, aids, dose and frequency; missing instructions must be completed before use, including by hand.
Browse illustrated exercise options
Short educational and functional phase in elective cases; not applicable to acute cases needing immediate treatment.
Short educational and functional phase in elective cases; not applicable to acute cases needing immediate treatment.
Short educational and functional phase in elective cases; not applicable to acute cases needing immediate treatment.
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
When motion and muscle activation are permitted and you can keep the knee straight without it sagging; practise first with the physiotherapist.
Only when some foot contact is permitted. The figure does not show a fully non-weight-bearing pattern: if contact is prohibited, you need specific instruction.
Only after clearance for full weight bearing and strengthening; use the range selected by the physiotherapist.
When knee flexion, foot contact and pushing through both feet are allowed. This is not a non-weight-bearing exercise.
After clearance for full weight bearing and single-leg support; practise first with the physiotherapist.
Only if the treating clinician permits cycling, pedal loading and the movement range. Cycling is not equivalent to complete offloading.
After recovering a controlled step-up and receiving clearance for single-leg eccentric work; walking clearance does not automatically permit it.
Only after running clearance under this protocol and assessment of motion, strength and control. Also respect the protection period for the injury or operation.
Only after jump clearance and an on-the-spot landing check by the physiotherapist. The figure shows the forward progression, to introduce with them.
After tolerating straight-line running and receiving specific clearance for braking and direction changes. First practise with the physiotherapist; this is not an initial running exercise.
Choose the current phase to prepare a printable sheet.
Phase safety summary ·
COMPLETE BEFORE EXERCISING — The treating team must complete the blank instructions, including handwritten entries, before this sheet is used.
Follow the assigned phase and instructions confirmed by the treating team; filling in fields does not authorise exercise.
No exercises assigned. This is a safety summary, not a complete exercise prescription.
Individual instructions for this phase
Loading (how much weight on the leg): ________________________________
Brace and crutches: ________________________________
Procedure and starting conditions
Operation report and prescription: Record procedure, site/size, fixation stability and associated operations. Obtain prescribed weight bearing, range and brace settings before exercise.
Lesion site: Weight bearing for a condylar lesion and loaded flexion for a patellofemoral lesion need different limits: record them in the personal plan.
Progression: Motion, loading and impact require separate clearance; strength tests do not establish biological healing. Functional checks are a practical checklist adapted from the sources, not validated paediatric return-to-sport tests.
Advice before starting
Perform only the exercises selected for you, at the prescribed dose. If permitted loading or movements are missing from your handout, ask for these to be completed before starting.
Do not try running or hopping to check whether you have healed.
Report pain or swelling that develops after the session too.
Warning signs: stop and contact the treating team
Fever, increasing wound redness or warmth, or drainage: contact the surgical team the same day, even without fever.
Increasing pain, new locking, persistent swelling or loss of regained movement: stop progression and arrange reassessment.
A cold or pale foot, reduced sensation or severe pain under a cast/brace needs urgent assessment. Breathing difficulty or chest pain is an emergency.
A framework to personalise with the orthopaedic clinician and physiotherapist, not a replacement for an individual prescription. Respect protection and clinical criteria, not dates alone.
A framework to personalise with the orthopaedic clinician and physiotherapist, not a replacement for an individual prescription. Respect protection and clinical criteria, not dates alone.
