Paediatric pathway tailored to maturity, surgical technique and remaining growth.
For younger adolescents, pivoting sport generally no sooner than 12 months, with function and growth review.
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
This pathway covers patients with open growth plates. All-epiphyseal, transphyseal, hybrid or extra-physeal techniques and associated procedures need different protection; all-inside alone does not tell whether the physis is crossed. Family and physiotherapist need written instructions on loading, brace, motion and growth follow-up.
Technique and protection
Record technique, graft, fixation and associated procedures. Early loading, brace and range of motion (ROM) follow operative instructions; there is no single paediatric schedule.
Age and progression
Adapt exercises and tests to maturity; maximal hop tests and adult scores are not universal requirements for younger children.
Growth
Monitor alignment and limb length during growth according to the surgeon’s plan; new changes need reassessment.
Operation instructions state how much loading and knee flexion are allowed. If permitted loading or movements are missing from your handout, ask for these to be completed before starting.
Exercises progress with strength and control; one test does not decide return.
Pivoting sport requires time, full training and growth follow-up.
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.
Preoperative preparation (prehabilitation)
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Goals
Full extension, or symmetrical to the uninjured knee.
Near-full flexion.
Minimal effusion (a "dry" knee).
Walking without significant limp, ideally without crutches.
Good voluntary quadriceps control and activation, with no extension lag.
Strength recovery compatible with the clinical picture of the injured limb.
Education on brace, crutches, allowed weight bearing and the early post-operative phases.
Preparation plan
Effusion and pain control (ice, elevation, load management).
Practical education on brace, crutches, allowed weight bearing and the goals of the first weeks.
Daily home programme, alongside physiotherapy sessions.
Precautions
Locked knee or bucket-handle meniscal tear: surgery should not be postponed to complete weeks of prehabilitation.
Repeated giving-way episodes: not an automatic indication, but they may make it appropriate to bring forward the surgical decision, especially if they limit daily life or expose the knee to new meniscal or chondral injuries.
Criteria checked by the treating team
Full or symmetrical extension and near-full flexion.
A dry knee, or a stable minimal effusion.
Smooth gait, without antalgic limp.
Effective quadriceps contraction, with no extension lag on straight leg raise.
The young patient and family can use crutches and brace and understand the first post-operative weeks.
When preparation is useful
When the clinical picture and surgical timing allow, the preoperative phase is an integral part of the pathway, not a side note.
It is particularly useful with a still swollen or stiff knee, an extension deficit or quadriceps inhibition after the injury.
It is carried out with the physiotherapist, with an agreed daily home programme.
In the growing patient, preparation also includes educating the family on the post-operative pathway and growth follow-up.
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.
Preoperative preparation may improve pre-surgical strength and function and support early recovery after reconstruction. It is not a guarantee of the final outcome: the post-operative pathway remains decisive. Dosages and duration are indicative and must be adapted by the physiotherapist.
Quadriceps isometric contraction (quad set)
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
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.
Straight leg raise (only if there is no extension lag)
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
First contract the quadriceps and lock the knee in full extension.
Lift the straight leg about 30 cm keeping the knee straight, then lower it slowly.
If the knee drops into flexion during the lift (extension lag), stop and work on quad sets first.
Dose and progression: Indicative: 2-3 sets of 8-10 repetitions. To be adapted with the physiotherapist.
Extension recovery with the heel supported
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Lying down, rest only the heel on a low support leaving the knee unsupported.
Let the knee drop under gravity with the thigh relaxed; a gentle quadriceps contraction can be added.
Do not force and do not push abruptly on the knee: extension returns with time and relaxation.
Dose and progression: Indicative: 3-5 minutes, several times a day if well tolerated.
Heel slides / active-assisted flexion
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Lying down, slide the heel toward the buttock keeping the foot in contact with the surface.
You may assist with your hands or a towel around the leg, staying within the pain-free range.
Return slowly to the start position, regaining full extension.
Dose and progression: Indicative: 10-15 repetitions, 2-3 times a day.
Mini squat or sit-to-stand within the tolerated range
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Standing, bend the knees only within the pain-free range (usually within 45-60°), keeping the knee aligned over the foot.
Alternatively, stand up and sit down from a comfortable chair height, sharing weight between both legs.
Avoid knee valgus collapse and trunk twisting.
Dose and progression: Indicative: 2-3 sets of 8-12 repetitions, on alternate days or as advised.
Bridge
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
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.
Single-leg balance (only if safe)
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Standing near a support, load one leg keeping the knee slightly flexed and the pelvis level.
Stop if pain, giving-way sensation or instability appear.
Dose and progression: Indicative: 3-5 holds of 20-30 seconds per side.
Stationary bike
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
To be introduced when range of motion and pain allow: raise the saddle if flexion is still limited.
Continuous pedalling at low resistance, pain-free and without increased swelling in the following hours.
Dose and progression: Indicative: 10-20 minutes, as tolerated.
Crutch and weight-bearing training
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
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.
Phase 1 · Protection and family
Early weeks, according to technique
Goals
Reduce effusion and regain permitted extension.
Activate the quadriceps.
Physiotherapy plan
Quadriceps isometrics within written limits; straight-leg raise only if permitted and without lag.
Teach child and family safe use of aids and brace.
Precautions
No loading or flexion beyond operative limits; no twisting.
Criteria the treating team checks before progression
Decreasing effusion and improving quadriceps control.
Safe gait with permitted loading and aids.
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.
Phase 2 · Motion and strength
After initial protection, according to reviews
Goals
Restore motion and gait.
Build age-appropriate strength and control.
Physiotherapy plan
Dynamic strength with partial squats, hip and trunk work only within cleared motion and loading.
Start balance with safe support, then progress to single-leg and developmentally suitable coordination tasks.
Precautions
Lack of pain alone does not permit jumps or cutting.
Criteria the treating team checks before progression
Better motion and gait without reactive effusion.
Progressing strength and age-appropriate single-leg control.
Illustrated exercise options
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.
Phase 3 · Guided running and impact
During later months, when criteria are met
Goals
Tolerate straight-line running then progressive impact.
Physiotherapy plan
Before running: restored motion and no effusion; assess quadriceps strength with maturity-appropriate tests (dynamometry if reliable), recording both limbs' values. Check step-down and single-leg control; interpret instrumented symmetry cautiously in prepubertal children. Respect surgical protection: the adult Aspetar threshold does not automatically apply.
Add landings then simple jumps only with adequate motion, strength and control and no joint reaction; use age-appropriate tests.
Precautions
No competition, contact or unplanned pivoting.
Criteria the treating team checks before progression
Restored motion, absent or minimal effusion and adequate strength.
Controlled running and impact without later worsening.
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.
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.
Phase 4 · Progressive return to sport
Graded training; pivoting competition usually no sooner than 12 months in ages 10-16
Goals
Restore sport skill, confidence and conditioning.
Physiotherapy plan
After controlled running and landing, add planned deceleration and cutting, then reactive tasks; move from individual to partial then full group training.
Continue neuromuscular prevention with family and coaches.
Precautions
Neither elapsed time nor one symmetrical test authorises competition.
Criteria the treating team checks at the end of the pathway
Several maturity-appropriate measures of strength, function, movement and confidence.
Full training tolerated and growth followed according to plan.
Illustrated exercise options
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.
Return to sport / full activity
For ages 10-16, consider at least 12 months before pivoting competition; at 17-18, decide according to maturity and individual criteria. Time alone is not clearance.
Knee without reactive effusion or giving way, with restored motion.
Strength, function and movement quality assessed with age- and maturity-appropriate tasks.
Full training tolerated, confidence and an active prevention programme.
Paediatric consensus largely reflects expert opinion; no single cut-off is validated. Family, surgeon and physiotherapist share the decision.
Warning signs: stop and contact the treating team
Fever or a red/draining wound: contact the team promptly.
New locking, giving way or increasing effusion: stop and seek reassessment.
New limb-length or alignment difference: inform the surgeon.
New calf pain with swelling: seek urgent medical assessment the same day.
Sudden breathing difficulty or chest pain: seek emergency medical help immediately.
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
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
Indicatively 2-6 weeks before surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
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 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.
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
Technique and protection: Record technique, graft, fixation and associated procedures. Early loading, brace and range of motion (ROM) follow operative instructions; there is no single paediatric schedule.
Age and progression: Adapt exercises and tests to maturity; maximal hop tests and adult scores are not universal requirements for younger children.
Growth: Monitor alignment and limb length during growth according to the surgeon’s plan; new changes need reassessment.
Advice before starting
Operation instructions state how much loading and knee flexion are allowed. If permitted loading or movements are missing from your handout, ask for these to be completed before starting.
Exercises progress with strength and control; one test does not decide return.
Pivoting sport requires time, full training and growth follow-up.
Warning signs: stop and contact the treating team
Fever or a red/draining wound: contact the team promptly.
New locking, giving way or increasing effusion: stop and seek reassessment.
New limb-length or alignment difference: inform the surgeon.
New calf pain with swelling: seek urgent medical assessment the same day.
Sudden breathing difficulty or chest pain: seek emergency medical help immediately.
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.
