Knee OCD: conservative rehabilitation
Protection and functional recovery for stable juvenile knee osteochondritis dissecans, after orthopaedic assessment. Activity, loading and return also depend on the lesion’s course on imaging.
A pathway over months: scheduled reviews; progression according to stability, healing and function
Prepare the visit handout
Use the condition and phase indicated by your clinician. You can leave out individual exercises; instructions, illustrations and safety advice remain together.
Changing phase restores its full exercise list. Timing alone does not determine the phase.
Exclude exercises if needed
14 of 14 exercise cards included
The full web page remains available. Your selection is not saved or shared.
This conservative rehabilitation pathway must be adapted to the injury, the treating clinician’s instructions and the individual response.
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.
At a glance — the full pathway
- Who it is for
- Stable juvenile OCD with confirmed conservative indication. Instability, a displaced fragment or joint locking require reassessment.
- Loading
- Record the prescription: unrestricted, protected or non-weight bearing, with any aids. Do not infer it from pain.
- Initial sport
- Stop running, jumping and impact sports; agree school arrangements, walking and alternative activities.
- Exercises
- Only selected exercises, within permitted motion and resistance. Do not remove a cast or brace to follow a figure.
- Reviews
- Clinical reviews and serial X-rays as planned; MRI when useful for stability or progress. Arrange the next review at the consultation.
- Plan reassessment
- If clinical or imaging progress is absent over the treatment months, reconsider the strategy. Do not continue an unchanged programme indefinitely.
This pathway covers a lesion assessed as stable by the orthopaedic clinician, particularly in a young person with open growth plates. It does not allow self-assessment of stability from an MRI report and is not the protocol after drilling, fixation or grafting.
Step by step
Each phase offers exercise options: perform only those selected by your clinician, without bringing later phases forward or automatically adding earlier exercises. Dosage, frequency and rests are individualised; the complete catalogue is not a single session.
Phase 1 — Lesion protection
Indicative timing: Initial period, often about 4-6 weeks; individual selection
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Reduce impact on the lesion
- •Control pain and effusion
- •Arrange school and travel
What to do
- •Respect prescribed loading and immobilisation; learn to use aids if needed
- •Gentle quadriceps activation only if explicitly allowed
- •Record pain, swelling and limitations for review
Restrictions and precautions
- •No running, jumping, pivoting or deep squats
- •Do not try hop tests to check whether the knee has healed
Exercises for this phase
1. Gentle quadriceps activationOnly if the treating clinician permits this contraction during protection; respect prescribed immobilisation and position.
- •Lie with the leg supported in the permitted position and gently tighten the front of the thigh.
- •Do not lift the heel, push on the knee with your hands or add weights.
- •Relax completely between attempts. Stop if joint pain develops.
Dosage: Starting example to confirm: 5-10 brief, pain-free contractions of 3-5 seconds. Frequency selected by the treating clinician.
Ready for the next phase when
- ☐Stable or improving symptoms, without locking
- ☐Protection programme followed
- ☐Orthopaedic review and clearance before changing loading or immobilisation
Note for the physiotherapist
Obtain lesion site, skeletal maturity, stability assessment and written loading, brace and ROM instructions. Record pain, effusion, permitted motion and school difficulties. Teach transfers and aids suited to the actual limit: the foot-contact illustration does not apply to complete offloading. Agree the next review and whom to contact if symptoms worsen.
Phase 2 — Permitted motion and activation
Indicative timing: After review and motion clearance
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Recover functional motion
- •Limit strength loss without adding impact
What to do
- •Heel slides and quadriceps activation; SLR without loss of extension and hip work if selected
- •Gait retraining within the foot-contact limit, without stopping aids prematurely
- •Gradually recover prescribed motion; do not independently add resistance or aerobic activity involving loading
Restrictions and precautions
- •No impact even if pain has resolved
- •Unloaded motion does not automatically permit resistance or deep flexion
Exercises for this phase
2. Heel slideAfter clearance for motion and any brace removal; only within the prescribed range.
- •Lie on your back and slide the heel towards the pelvis along the supporting surface.
- •Stop at the permitted movement limit, even if the figure shows greater flexion.
- •Return slowly without forcing, pulling with a strap or adding resistance.
Dosage: Starting example to confirm: 5-10 slow movements; frequency and range selected by the treating clinician.
3. Controlled straight-leg raiseWhen 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.
Dosage: Starting suggestion: 1 set of 5-8 controlled repetitions, to confirm. Stop before the knee loses extension; frequency as prescribed.
4. Side-lying hip abductionFor a hip-strength deficit identified by the physiotherapist, when side-lying and movement are allowed.
- •Lie on the instructed side with the exercising leg on top and the pelvis still; the position must not press on wounds or breach the other limb’s restrictions.
- •Slightly raise the upper leg without rolling the pelvis backwards; keep the foot relaxed.
- •Lower slowly without loading the foot. No bands or ankle weights; do not remove a cast or brace, whose weight may make this exercise unsuitable.
Dosage: Example to adapt: 1-2 sets of 6-10, stopping if control is lost. Frequency and side selected by the physiotherapist.
5. Walking with crutches and prescribed foot contactOnly 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.
Dosage: Agreed short distances with rests; duration and frequency depend on prescribed loading and gait quality.
Ready for the next phase when
- ☐Permitted movement recovered without new effusion
- ☐Authorised activities tolerated
- ☐Clearance for increased loading and functional strengthening
Note for the physiotherapist
Assess active ROM, any loss of extension during SLR and hip control, without maximal tests. Select a few activation exercises that cause no joint pain or effusion and teach how to report the response afterwards. Tolerated motion does not itself permit greater loading. Cycling is offered in the next phase unless individual instructions differ.
Phase 3 — Strength and control without impact
Indicative timing: Over the following months, according to reviews and permitted loading
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Recover knee strength and control
- •Maintain aerobic capacity compatible with protection
What to do
- •Select bridging, mini-squats, step work, calf strengthening and balance only within permitted loading and range
- •Restore hip and knee strength without impact or unauthorised deep flexion
- •Select easy stationary cycling for aerobic capacity and motion, checking the response after the session
Restrictions and precautions
- •No running or hopping without further clearance
- •Do not exceed plan restrictions to chase symmetry with the other leg
Exercises for this phase
6. Double-leg bridgeWhen 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.
Dosage: Starting example: 1-2 sets of 6-10 slow movements with rests, adapted to the response and overall session.
7. Supported mini-squatOnly after clearance for full weight bearing and strengthening; use the range selected by the physiotherapist.
- •Stand on firm ground with feet hip-width apart and one hand on a secure support.
- •Bend the knees slightly, keeping them aligned with the feet; do not aim for a deep squat.
- •Rise with control. Reduce the exercise and tell the treating clinician if pain or swelling develops after the session.
Dosage: Starting example to confirm: 1-2 sets of 6-10, with a rest. Loading and frequency individualised.
8. Supported low step-upAfter clearance for full weight bearing and single-leg strengthening; height and range selected by the physiotherapist.
- •Use a stable step, lower than the drawing if needed, near a handrail or secure support.
- •Place the whole treated foot on the step and rise slowly, keeping knee and foot aligned and the pelvis controlled.
- •Step down with assistance as taught. Do not add weights or increase height if pain, limping or swelling develops.
Dosage: Example to confirm: 1-2 sets of 5-8 step-ups with rests; do not pursue fatigue at the expense of movement quality.
9. Controlled low step-downAfter 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 even though it is not shown.
- •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.
Dosage: First attempt supervised; subsequent example: 1 set of 5-8 controlled step-downs. Agree volume and frequency.
10. Supported double-leg calf raisesOnly after clearance for full weight bearing and calf strengthening.
- •On a level floor, place your hands on a stable support even though it is not shown in the figure.
- •With both feet, slowly raise the heels and lower them with control.
- •Do not independently progress to one leg or a step edge. Stop for joint pain and monitor the subsequent response.
Dosage: Starting example to confirm: 1-2 sets of 6-10 with a rest; dose and frequency adapted to the response.
11. Firm-ground balanceAfter 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 without aiming for the height shown in the figure.
- •Keep a stable hand support within reach even though it is not drawn; 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.
Dosage: Starting example to confirm: 3 brief attempts of 10-20 seconds with rests; stop before losing control.
12. Easy stationary cyclingOnly 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. Stop for joint pain or subsequent swelling.
Dosage: Suggested start to confirm: 3-5 easy minutes with rests if needed; progress one variable after checking the response.
Ready for the next phase when
- ☐No pain or effusion with agreed activities
- ☐Mobility, strength and control adequate for the next tasks
- ☐Favourable healing progress on imaging and orthopaedic impact clearance
Note for the physiotherapist
Select hip, quadriceps and calf strengthening, step control and balance according to assessment; do not combine every card. Bridging loads the feet; step-downs and single-leg work are separate progressions. Measure strength and movement quality with age-appropriate tools. Increase one variable after a favourable response including the next day; new effusion requires stopping progression and consulting the treating clinician.
Phase 4 — Graded return to sport
Indicative timing: Only after clinical clearance and healing assessment
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Gradually resume impact and sporting skills
- •Tolerate full training
What to do
- •Running intervals and small hops on firm ground after demonstration
- •Progress towards direction changes and training in the relevant sport
- •Review the plan if pain or swelling return
Restrictions and precautions
- •No return based solely on elapsed months
- •Do not compete before a full training session is tolerated
Exercises for this phase
13. Small two-foot hopsOnly after impact clearance and demonstration by the physiotherapist. Do not use this exercise to decide whether the lesion has healed.
- •Start with small two-foot hops on the spot on a firm, even surface.
- •Aim for a controlled landing; forward, sideways and single-leg hops are separate progressions requiring clearance.
- •Stop for pain or loss of control and report pain or swelling afterwards.
Dosage: Initial attempts and dose selected by the physiotherapist; increase only after checking the subsequent response.
14. Graded running and direction changesOnly after impact and running clearance. Direction changes need a further check; the figure shows an advanced progression.
- •Start with the agreed straight-line run/walk programme on level ground.
- •Once this is tolerated, practise slowing down and wide turns at low speed under supervision; rapid and reactive cuts come later.
- •Increase one demand at a time: duration, speed or complexity. Stop for pain, giving way, limping or swelling and check the next-day response too.
Dosage: Intervals, rests and recovery days selected for age, sport and previous level. No independent maximal tests; tolerate full training before competition.
Ready for the next phase when
- ☐No pain, locking or new swelling during or after sessions
- ☐Strength and control assessed for age and sport
- ☐Full training tolerated and final treating clinician clearance
Note for the physiotherapist
Impact first requires orthopaedic assessment of healing, not a home hop test. Assess strength, single-leg control, landing, deceleration and confidence with selected tasks, without universal paediatric thresholds. Progress through straight-line run/walk intervals, controlled jumps, direction changes and sport training, with agreed rests. Symmetry between two deconditioned limbs is insufficient; assess movement quality and overall capacity too.
If symptoms appear after a progression
If persistent pain, effusion or swelling, or loss of movement appears after moving to a new phase or increasing load, stop progression and contact the treating clinician or physiotherapist to review the programme. Seek prompt assessment for the red flags below. This document does not replace individual clinical assessment.
Return to sport / full activity
Think in months, often with an initial 3-6-month treatment period and further reviews according to progress. This window is for treatment reassessment: it neither guarantees healing nor authorises sport.
- ☐Healing assessed by the orthopaedic clinician using clinical findings and imaging
- ☐No pain, locking or effusion with authorised activities
- ☐Motion, strength and control adequate for the sport
- ☐Full training tolerated without a next-day reaction
- ☐Clearance agreed with the clinician and physiotherapist
If healing does not progress, reassess diagnosis, adherence, stability and treatment options. Conservative care must not become unmonitored waiting.
Red flags: stop and contact us
- •Knee locking or sudden inability to straighten: prompt assessment without forcing
- •New substantial effusion, giving way or increasing pain: stop progression and contact the orthopaedic clinician
- •New inability to bear weight or persistent rest/night pain: reassessment
- •Fever with a hot, swollen knee: urgent assessment
Author: Dott. Daniele Priano, Paediatric Orthopaedics. Content version: 9 September 2026.
Timings are indicative: progression depends on clinical and functional criteria and on the treating clinician’s instructions.
Frequent questions
If pain has gone, can running resume?
Not automatically. The treating clinician must integrate symptoms, function and lesion progress on imaging before clearing impact. The young person should not try test hops at home.
Full introduction and references at ortopediaevolutiva.com/en/rehabilitation/knee-osteochondritis-dissecans-conservative
Knee OCD: conservative rehabilitation — Dott. Daniele Priano, Pediatric Orthopaedics · Information document: it does not replace an in-person assessment.
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Email: daniele.priano@ortopediaevolutiva.com