Tibial Spine (Eminence) Fracture: reduction and fixation with bioabsorbable pins
Recovery after tibial-spine avulsion fixation, with initial protection and guided restoration of movement.
SmartNail: 30 days in extension and non-weight-bearing; then progression after 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 describes the agreed SmartNail practice: 30 days immobilised in extension and 30 days non-weight-bearing. This is not a rule for every fixation; other techniques or associated injuries need their own instructions.
Prescription
Confirm technique, stability, any meniscal injury and loading/motion limits. For SmartNail follow the agreed 30 days unless the surgeon prescribes otherwise.
Motion
After protection, measure extension and flexion at each review. Persistent stiffness needs prompt discussion with the surgeon, not forced mobilisation.
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 (educational)
In the hours or days before surgery: this is a traumatic lesion that often needs early treatment.
Goals
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).
Preparation plan
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.
Precautions
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.
Criteria checked by the treating team
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 preparation is useful
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.
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
In the hours or days before surgery: this is a traumatic lesion that often needs early 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.
1. Fixation protection
SmartNail: first 30 days
Goals
Maintain protection and independent transfers.
Physiotherapy plan
Non-weight-bearing crutch use; brace/cast in extension as prescribed.
Static quadriceps contractions in extension and permitted hip work; leg raise only without sagging and with the brace if indicated.
Precautions
No bending or weight bearing outside the prescription.
Criteria the treating team checks before progression
Favourable surgical review.
Written clearance for motion and loading progression.
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
Only if permitted during protection, keeping the knee extended and the brace as prescribed; first attempt assisted. Do not unlock the brace to perform the exercise. If a cast is present, use only the specific variation taught and authorised by the team.
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. Movement and walking
After review and the protection period
Goals
Recover extension, then flexion and gait.
Physiotherapy plan
Gentle active/assisted motion within prescribed limits; no weights to force extension.
Loading progression and aid reduction according to control.
Precautions
Do not force 90° or other time targets with painful manoeuvres.
Criteria the treating team checks before progression
Movement improving without locking.
Permitted loading tolerated and quadriceps controlled.
Illustrated exercise options
Prone hang (passive extension)
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
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.
Dose and progression: Duration and repetitions prescribed by the physiotherapist; do not perform during immobilisation.
Heel slide
After 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.
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.
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.
3. Strength and control
After loading recovery
Goals
Restore strength and functional stability.
Physiotherapy plan
After loading recovery, progress from static control to mini-squats, low steps and dynamic hip strengthening within the cleared range.
Supported firm-ground balance, then single-leg balance if stable; non-impact conditioning.
Precautions
No running or hopping until healing and function allow.
Criteria the treating team checks before progression
Walking without a limp and no reactive effusion.
Union assessed and impact cleared.
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.
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.
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.
4. Sport preparation
After impact clearance
Goals
Restore running, landing and direction changes.
Physiotherapy plan
After confirmed healing and impact clearance, interval straight-line running, then small hops with controlled landings.
Only after good tolerance and landing control, progress to supervised deceleration and direction changes.
Precautions
Do not progress with giving way, pain or new swelling.
Criteria the treating team checks before progression
Assess low steps and single-leg control without giving way; record quadriceps force with a dynamometer if available and compare over time.
Progressive sport-specific tasks tolerated.
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.
5. Return
After recovery and review
Goals
Tolerate training and competition.
Physiotherapy plan
Progress from partial to full training.
Maintain strength and neuromuscular control.
Precautions
A symmetry test alone does not rule out stability problems.
Criteria the treating team checks at the end of the pathway
Full training tolerated.
Clinical stability and return assessed by the surgeon.
Return to sport / full activity
Return follows union and functional recovery; there is no identical deadline for every fixation.
Union and stability assessed; no locking or giving way.
Document motion, quadriceps strength (dynamometer if available), steps and, after impact clearance, controlled landings and deceleration.
Full training without subsequent effusion or pain.
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
In the hours or days before surgery: this is a traumatic lesion that often needs early treatment.
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
Only if permitted during protection, keeping the knee extended and the brace as prescribed; first attempt assisted. Do not unlock the brace to perform the exercise. If a cast is present, use only the specific variation taught and authorised by the team.
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
After clearance for motion and any brace removal; only within the prescribed range.
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 recovering a controlled step-up and receiving clearance for single-leg eccentric work; walking clearance does not automatically permit it.
After clearance for full weight bearing and single-leg support; practise first with the physiotherapist.
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
Prescription: Confirm technique, stability, any meniscal injury and loading/motion limits. For SmartNail follow the agreed 30 days unless the surgeon prescribes otherwise.
Motion: After protection, measure extension and flexion at each review. Persistent stiffness needs prompt discussion with the surgeon, not forced mobilisation.
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.
