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 months
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
12 of 12 exercise cards included
The full web page remains available. Your selection is not saved or shared.
This protocol is part of the post-operative pathway and must be adapted to the surgeon’s instructions and to the individual clinical 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
- Brace
- Brace locked in extension or a cast for 30 days, day and night, unless the surgeon indicates otherwise.
- Weight bearing
- Non-weight bearing (foot not placed on the ground) with crutches for the first 30 days; progressive loading only after the clinical and radiographic review, with full weight bearing usually between weeks 6 and 8.
- ROM
- Knee kept in extension during the first month; flexion is started and progressed after the one-month review, usually 0-60° within a few days, 0-90° by week 6 and full ROM between weeks 8 and 10.
- Main risk
- Arthrofibrosis (loss of extension or flexion). If flexion is not progressing or full extension is missing at the second-month review, immediate clinical reassessment is required, not watchful waiting.
- Bone healing
- Radiographic check at about 4 weeks; union generally over a few weeks, confirmed clinically and radiographically.
- Running
- Usually from months 3-4, with full ROM, a dry knee and quadriceps ≥80%.
- Return to sport
- Non-contact sport at 4-6 months; pivoting and contact sport at 6-9 months with functional tests passed and clinical stability.
In children and adolescents with open physes, the bone of the intercondylar eminence is weaker than the anterior cruciate ligament attached to it. A twisting injury that would tear the ligament in an adult therefore avulses a bony fragment from the tibial plateau instead: this is a tibial spine (eminence) fracture. The ACL generally remains attached to the fragment, but it may have stretched at the time of injury and associated meniscal or chondral lesions can coexist.
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.
Before surgery — Preparation for surgery (educational)
In the hours or days before surgery: this is a traumatic lesion that often needs early treatment.
When it applies
- •No prehabilitation programme applies: the tibial spine fragment must not be stressed.
- •Preparation is purely educational and organisational, addressed to the young patient and the family.
Goals before surgery
- •Understand the immobilisation and knee position planned after surgery.
- •Understand initial off-loading and crutch use.
- •Know the post-operative goals of the first weeks (extension, muscle activation, gradual flexion recovery).
- •Know which warning signs to report immediately (worsening pain, rapid swelling, changes in sensation or movement, change in colour or temperature of the foot).
Activities
- •Crutch training with the prescribed off-loading, avoiding any movement that loads or mobilises the injured knee.
- •Explanation of the brace/immobilisation and of transfers (bed, chair, car, bathroom).
- •No exercises of the injured knee before surgery.
Preoperative exercises
Crutch and weight-bearing training
- •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.
Dosage: At least one training session before admission; repeat until the technique is safe.
Readiness criteria for surgery
- ☐The young patient moves safely with crutches, without loading the limb.
- ☐Family informed about immobilisation, timing and post-operative goals.
- ☐Paperwork and home arrangements ready for admission.
When surgery must not be delayed
- •Tibial spine avulsion is a traumatic lesion: treatment must not be postponed for rehabilitation reasons.
- •Knee blocked short of extension by fragment interposition: timely treatment.
What to prepare at home and school
- •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.
Phase 1 — Protecting the fixation in extension, non-weight bearing
Indicative timing: Days 0-30
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Protect the fixation and maintain the reduction
- •Maintain full extension
- •Prevent quadriceps inhibition
What to do
- •Brace locked in extension or a cast, day and night, for 30 days
- •Non-weight bearing with crutches: the foot is not placed on the ground, unless the surgeon indicates otherwise
- •Isometric quadriceps contractions and braced straight-leg raises several times a day
- •Active ankle and hip mobilisation, patellar mobilisation if permitted and if the immobilisation allows it
- •Cryotherapy and compression, limb elevated; dressings and wound care as instructed at discharge
Restrictions and precautions
- •No weight bearing on the operated limb
- •No knee flexion beyond what is expressly authorised
- •No resisted hamstring work
- •No twisting or activity on slippery ground
Exercises for this phase
1. Quadriceps isometric contraction (quad set)After entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •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.
Dosage: 10 contractions of 5 seconds, 4-6 times a day
2. Straight-leg raiseAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Lying on your back, first tighten the thigh until the knee locks straight.
- •Lift the straight leg about 30 cm, hold 3 seconds and lower slowly.
- •If the knee bends while lifting, the quadriceps is not ready yet: go back to quad sets.
Dosage: 3 sets of 10, twice a day
Ready for the next phase when
- ☐Healed wound
- ☐Good quadriceps control within the brace
- ☐Decreasing pain and effusion
- ☐Clinical and radiographic review at 4 weeks confirming the reduction is maintained
Note for the physiotherapist
In this first month the aim is not to gain degrees of flexion but to protect the fixation: useful work means isometric quadriceps recruitment and maintaining extension. Motion progression starts after the radiographic review and is agreed with the surgeon.
Phase 2 — Restoring flexion and weight bearing
Indicative timing: From day 30 (after the clinical and radiographic review) to week 8
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Restart flexion after the radiographic review and reach 90° by week 6
- •Full weight bearing without limp
- •Quadriceps reactivation
What to do
- •Start and guided progression of flexion once authorised: heel slides, gravity-assisted seated flexion, stationary bike with no resistance once past 100-105°
- •Progressive brace unlocking and weaning as directed by the surgeon
- •Load progression from touch-down to full weight bearing, usually between weeks 6 and 8; mirror gait re-education
- •Closed-chain strengthening once loading is allowed: mini-squats 0-45°, glute bridge, low-load leg press
- •Recover extension only after the protected phase and permission to mobilise, using a physiotherapist-taught position and dose. No added ankle weights at home.
Restrictions and precautions
- •No impact, no running
- •No aggressive forced passive flexion
- •Progression always subject to radiographic confirmation of union
Exercises for this phase
3. Prone hang (passive extension)After entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Only after the protection period, fixation review and movement clearance: first ask your physiotherapist for a demonstration.
- •Lie prone on the treatment couch with the thigh supported and the lower leg beyond the edge, in the position demonstrated.
- •Allow gravity to act within the permitted range, without pushing or ankle weights. Stop for pain or intolerable tension.
Dosage: Duration and repetitions prescribed by the physiotherapist; do not perform during immobilisation.
4. Heel slides (flexion recovery)After entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Lying on your back, slowly slide the heel towards the buttock.
- •Stop at the angle allowed by the protocol, hold 5 seconds and return.
- •A towel under the heel makes sliding easier.
Dosage: 3 sets of 10, 3 times a day
5. Load progression using scalesAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Practise first with your physiotherapist, using crutches and stable supports to prevent falls.
- •Place the foot on the scales only if weight bearing is allowed and reach only the prescribed value. A percentage depends on your body weight and is not a fixed number of kilograms.
- •Scales help you recognise static loading but do not certify loading while walking. Do not increase it automatically each week.
Dosage: 5 minutes of load training per day
Ready for the next phase when
- ☐At least 90° flexion at 6 weeks and progressing toward full ROM
- ☐Full extension maintained
- ☐Walking without crutches and without limp
- ☐Absent or minimal effusion
Note for the physiotherapist
If flexion does not progress after unlocking, or extension is incomplete, inform the surgeon immediately: this is the window in which targeted mobilisation prevents further surgery.
Phase 3 — Strength and knee control
Indicative timing: Months 2-4
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Stable, full symmetrical ROM
- •Quadriceps ≥80% of the other side
- •Single-leg alignment control
What to do
- •Progressive strengthening: squats, lunges, step-ups and step-downs, single-leg press, single-leg bridge
- •Posterior chain and hamstrings (introduced gradually, without early maximal loads)
- •Single-leg proprioception, unstable surfaces, dual task
- •Bike, swimming, elliptical for conditioning; introduction of deep-water running
- •Stability assessment (Lachman, pivot shift and any instrumented testing) is performed by the surgeon at scheduled reviews, not in the gym or at home
Restrictions and precautions
- •No cutting or full-intensity sport-specific drills
Exercises for this phase
6. Mini-squat 0-45°After entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Standing, feet hip-width apart, weight evenly distributed.
- •Bend the knees to about 45°, keeping the knees aligned over the feet.
- •Rise by pushing through the heels, without letting the knee collapse inwards.
Dosage: 3 sets of 12, 3-4 times a week
7. Glute bridgeAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Lie on your back, knees bent, feet flat on the floor.
- •Lift the pelvis by squeezing the glutes until shoulders, hip and knee are aligned.
- •Lower slowly without arching the back.
Dosage: 3 sets of 12-15, on alternate days
8. Controlled step-downAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Stand on a 15-20 cm step on the operated leg.
- •Lower slowly with the other foot, touching the floor with the heel, over 3 seconds.
- •The standing knee must stay aligned over the foot: if it collapses inwards, lower the step.
Dosage: 3 sets of 8-10 per side, 3 times a week
9. Single-leg balanceAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Stand on one leg with the knee slightly bent and look ahead, after clearance for weight bearing.
- •Keep your eyes open on firm ground near a stable support; an adult must be able to assist the child.
- •Aim to keep your pelvis steady. If it tilts or you lose balance, put the other foot down, reduce the difficulty and ask your physiotherapist to check the movement.
Dosage: 3 x 30 seconds per side, daily
Ready for the next phase when
- ☐Full symmetrical ROM
- ☐Quadriceps ≥80%
- ☐20 cm step-down without dynamic valgus or pain
- ☐No effusion after activity
Phase 4 — Running, impact and agility
Indicative timing: Months 4-6
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Running and plyometrics without symptoms
- •Strength ≥90%
- •Preparation for sporting skills
What to do
- •Interval return-to-running programme, 10% weekly volume progression
- •Progressive plyometrics: double-leg → single-leg → jumps with controlled landing
- •Linear agility, then wide and sharp cutting; deceleration work
- •ACL-injury prevention neuromuscular training (dynamic valgus control, landing mechanics)
Exercises for this phase
10. Progressive plyometricsAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •Only after clearance for impact and demonstration by your physiotherapist, start with small two-foot hops on a stable surface.
- •Increase direction, height or single-leg work only within the agreed progression; do not add several challenges at once.
- •Aim for a controlled landing with knees and feet aligned. Stop for pain, giving way or loss of control; report swelling or worsening symptoms afterwards. Landing noise alone does not measure movement safety.
Dosage: 2-3 sets of 10-20 contacts, 2-3 times a week
11. Agility and change of directionAfter entering the indicated phase and receiving clearance for this exercise; respect prescribed load and range.
- •After clearance, practise shuttle runs, figure-of-eight runs and cone slaloms: wide turns first, then sharper changes.
- •Add unanticipated direction changes only at the agreed stage, with the physiotherapist or trainer supervising the return to sport.
- •Stop for pain, the limb giving way or loss of movement control.
Dosage: 2 sessions a week, within training
Ready for the next phase when
- ☐20-30 minutes of continuous running without pain or swelling
- ☐Hop tests with LSI ≥85-90%
- ☐Quadriceps and hamstrings ≥90%
- ☐No giving-way episodes
Phase 5 — Return to sport and growth surveillance
Indicative timing: Months 6-9 and follow-up
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Graded return to competition
- •Confirm absence of growth disturbance
- •Prevent subsequent injury
What to do
- •Graded reintegration: partial training → full training → competition
- •Ongoing preventive neuromuscular programme (FIFA 11+ or equivalent)
- •Clinical follow-up in patients with open physes; radiographic review between 6 and 12 months only where indicated by age, remaining growth, implant trajectory or clinical suspicion of angular deformity or leg-length discrepancy
- •Education: mild residual laxity is common and does not contraindicate sport when functional stability is good
No additional exercise cards are assigned here. Follow this phase’s indications and the programme selected by your physiotherapist; do not automatically continue or progress every previous exercise.
Ready for the next phase when
- ☐Test battery with LSI ≥90%
- ☐Satisfactory clinical stability and no giving-way episodes
- ☐Full ROM maintained over time
- ☐Surgeon clearance and adequate subjective confidence, assessed in the clinical consultation
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
Non-contact sport usually at 4-6 months; pivoting and contact sport at 6-9 months. These are indicative windows: return criteria are similar to those used after ACL reconstruction but not identical, since stiffness, residual laxity, associated injuries and the demands of the specific sport weigh heavily here.
- ☐Quadriceps and hamstring strength with LSI ≥90%
- ☐Hop test battery (single, triple, crossover, 6 m timed) with LSI ≥90%
- ☐Full symmetrical ROM, no effusion
- ☐No giving-way episodes; stability assessed by the surgeon at review
- ☐Drop-jump landing without dynamic valgus
- ☐Pedi-IKDC or Lysholm ≥90 and adequate subjective confidence
The Limb Symmetry Index has known limitations: on its own it is not enough, because the uninjured side may also be deconditioned. It should be combined with absolute strength values, movement quality and sport-specific demands. In patients with open physes, clinical follow-up over the following months is advisable, with radiographs where indicated. Mild residual anterior laxity is common: when not associated with functional instability, it does not delay return to sport.
Red flags: stop and contact us
- •After mobilisation has started: loss of full extension, or flexion not progressing as expected at reviews (suspected arthrofibrosis: contact the surgeon)
- •Sudden locking (possible fragment or implant displacement)
- •Large persistent effusion or rapid recurrence after loading
- •Acute pain after a new injury with a sense of giving way
- •Fever, redness, warmth or discharge from arthroscopic portals
- •In growing patients: development of angular deformity or leg-length difference in the following months
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.
Full introduction and references at ortopediaevolutiva.com/en/rehabilitation/tibial-spine-fracture-fixation
Tibial Spine (Eminence) Fracture: reduction and fixation with bioabsorbable pins — Dott. Daniele Priano, Pediatric Orthopaedics · Information document: it does not replace an in-person assessment.
Latest online versionThis protocol may be used and shared for clinical and informational purposes provided that attribution to the author and to the original source is kept intact. Republishing or distributing it as one’s own work is not allowed.
Other protocols
Any questions?
For information or questions, email me or view the locations and contact details.
Email: daniele.priano@ortopediaevolutiva.com