Current Concepts For Rehabilitation and Return To Sport After Knee Articular Cartilage Repair in The Athlete

[ clinical commentary ]
KAI MITHOEFER, MD1 • KAREN HAMBLY, PT, PhD, MCSP2 • DAVID LOGERSTEDT, PT, PhD, MPT, SCS3
MARGHERITA RICCI, MD4 • HOLLY SILVERS, MPT5 • STEFANO DELLA VILLA, MD4
Current Concepts for Rehabilitation and

Return to Sport After Knee Articular
Cartilage Repair in the Athlete
A
cute and chronic injuries of the articular cartilage surfaces of the knee in the athlete frequently occur
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of the knee are frequently observed in athletes. A recent in association with other injuries, such as
ligament or meniscal tears, traumatic
systematic review demonstrated an average prevalence of full-
patellar dislocations, and osteochondral
thickness focal chondral defects in 36% of athletes.49 Defects injuries.104 Articular cartilage defects of
were located predominantly in the patellofemoral compartment the femoral condyles have been observed
Copyright © 2012 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
(37%) and femoral condyles (35%), and less frequently on the tibial in up to 50% of athletes undergoing an-
plateau (25%). Magnetic resonance imaging (MRI) evaluation of terior cruciate ligament reconstruction,
with an increased incidence in female
asymptomatic professional basketball world-class-level soccer players. In addi- athletes.143 Articular cartilage defects
players revealed articular cartilage ab- tion to the rising incidence of such inju- can also develop in the high-impact ath-
normalities in the knee of up to 89% of ries in high-level competitive athletes, the letic population from chronic, pathologic
the players,181 and cartilage injury has increase in recreational participation in joint-loading patterns that result from
been reported to exist in 20% of profes- pivoting sports such as football, basket- joint instability or malalignments.104 Irre-
sional American football players.19 Levy ball, and soccer has been associated with spective of their origin, articular cartilage
Journal of Orthopaedic & Sports Physical Therapy®
et al96 demonstrated an increasing inci- a rising number of sports-related articu- injuries will frequently limit the ability of
dence of chondral injuries over time in lar cartilage injuries in that population.6 the affected athletes to continue partici-
competitive collegiate, professional, and Injuries of the articular cartilage surface pation in their sport and predispose them
to progressive joint degeneration.88
TTSYNOPSIS: Articular cartilage injury is ob-
The limited ability of spontaneous
take into consideration the biology of the cartilage
served with increasing frequency in both elite and repair technique, cartilage defect characteristics, repair following acute or chronic articu-
amateur athletes and results from the significant and each athlete’s sport-specific demands to lar cartilage injury is well documented.77
acute and chronic joint stress associated with optimize functional outcome. Systematic, stepwise The lack of vascularization of articular
impact sports. Left untreated, articular cartilage rehabilitation with criteria-based progression is cartilage prevents the physiologic in-
defects can lead to chronic joint degeneration recommended for an individualized rehabilitation flammatory response to tissue injury and
and athletic and functional disability. Treatment of of each athlete not only to achieve initial return resultant repair. This failure of recruit-
articular cartilage defects in the athletic popula- to sport at the preinjury level but also to continue
tion presents a therapeutic challenge due to the ment of extrinsic, undifferentiated repair
sports participation and reduce risk for reinjury
high mechanical demands of athletic activity. cells combined with the intrinsic inabil-
or joint degeneration under the high mechani-
Several articular cartilage repair techniques have ity for replication and repair by mature
cal demands of athletic activity. J Orthop Sports
been shown to successfully restore articular chondrocytes results in a repair cartilage
Phys Ther 2012;42(3):254-273. doi:10.2519/
cartilage surfaces and allow athletes to return to that is both qualitatively and quantita-
jospt.2012.3665
high-impact sports. Postoperative rehabilitation
TTKEY WORDS: ACI, chondrocytes, microfracture,
tively insufficient. Repetitive loading of
is a critical component of the treatment process
for athletic articular cartilage injury and should OATS the injured articular cartilage, as occurs
in impact and pivoting sports, results in
1
Director, Center for Biologic Joint Restoration, Department of Orthopedics and Sports Medicine, Harvard Vanguard Medical Associates, Boston, MA. 2Lecturer and Director of
Learning and Teaching, Centre for Sports Studies, University of Kent, Medway, UK. 3Postdoctoral Researcher, Department of Physical Therapy, University of Delaware, Newark,
DE. 4Educational and Research Department, Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy. 5Director of Research, Santa Monica Orthopaedic and
Sports Medicine Research Foundation, Santa Monica, CA. Address correspondence to Dr Margherita Ricci, Educational and Research Department, Isokinetic Medical Group, FIFA
Medical Centre of Excellence, Via Casteldebole 8/4, Bologna, Italy 40132. E-mail: m.ricci@isokinetic.com
254 | march 2012 | volume 42 | number 3 | journal of orthopaedic & sports physical therapy
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further cellular degeneration with the development or progression of articular neocartilage repair tissue and include
accumulation of degradative enzymes cartilage defects. Concomitant pathologic osteochondral autograft transfer system
and cytokines, disruption of collagen factors such as ligamentous instability, (OATS) and allograft transplantation.
ultrastructure, increased hydration, and malalignment, and meniscal injury or In contrast, reparative procedures are
fissuring of the articular surface.100 In deficiency can further promote degenera- designed to produce a repair cartilage
a long-term study115 that examined the tive progression. tissue and include marrow stimulation
knees of 28 young athletes with isolated, Despite recent advances in surgical techniques using mesenchymal stem
severe chondral damage, 75% of these techniques to address articular cartilage cells (first- and second-generation mi-
athletes initially returned to sport; but injuries, recovery to previous levels of crofracture techniques) and all early
a significant decline of athletic activity activity is often delayed. Because of the and advanced chondrocyte-based repair
and resultant reduction of sports partici- vulnerable nature of articular cartilage techniques (autologous chondrocyte
pation were observed 14 years after the repairs, especially in the initial healing transplantation [ACI], characterized
initial injury. However, most patients stages, postsurgical rehabilitation of the chondrocyte implantation, and matrix-
continued to engage in individual fit- athlete has been identified as critically induced autologous chondrocyte im-
ness activities, 22 of whom were satisfied important, with the potential to influence plantation). A recent survey19 of National
with their knee function. Radiographic both patient outcome and quality of re- Football League team physicians reported
evidence of osteoarthritis was present in pair tissue.118 However, limited evidence- that microfracture was the most frequent
57% of these athletes, with older athletes based research exists on rehabilitation treatment approach (43%), followed by
having a higher incidence of arthritic after chondral repairs, especially in the debridement (31%), nonoperative treat-
changes than younger athletes. These re- athletic population. 32,56,62,147 Therefore, ment (13%), OATS (6%), osteochondral
sults are consistent with an up to 12-fold the purpose of this current-concepts pa- allograft (4%), and, last, chondrocyte-
increased risk of knee osteoarthritis in per is to discuss postoperative rehabilita- based repair (3%). Chondral lesion size
high-demand, pivoting athletes.36,88 tion of the athlete following an articular was the most important factor in deci-
Intact articular cartilage possesses cartilage repair procedure in the knee. sion making to determine the surgical
optimal load-bearing characteristics and The overall goal of postoperative reha- technique.
adjusts to the level of activity and the bilitation is to maximize patient recovery
loading demands of the joint. Increasing and outcomes, while facilitating cartilage Restorative Cartilage Repair Techniques
weight-bearing activity in athletes and healing and maturation and preventing The use of OATS for repair of focal chon-
adolescents has been shown to increase risk of further chondrocyte death or inju- dral and osteochondral lesions has been
the volume and thickness of articular ry. The development and implementation popularized by Hangody et al.63 This
cartilage.79,80 In the healthy athlete, a of criteria-based guidelines are presented technique provides a hyaline cartilage
positive linear dose-response relationship to inform clinical decision making and restoration by harvesting cylindrical os-
exists for repetitive-loading activities and guide rehabilitation progression from teochondral grafts from areas of limited
articular cartilage function.84,100 However, acute phases through return to sport. weight bearing (the intercondylar notch
recent studies in a canine model indicate or the medial and lateral trochlea), which
that this dose-response curve reaches a CARTILAGE SURGICAL are transferred into small to midsize (1-4
threshold and that activity beyond this TECHNIQUES cm2) defects of the weight-bearing joint
threshold can result in maladaptation surface using a press-fit technique. This
T
and injury of articular cartilage.84 High- reatment of articular carti- technique does not involve regeneration
impact joint loading beyond the capabil- lage injuries in the athletic popu- of a cartilage repair tissue. While im-
ities of the cartilage has been shown to lation has traditionally presented mediate hyaline cartilage restoration is
decrease cartilage proteoglycan content, a significant therapeutic challenge due achieved, bone-to-bone healing of the
increase levels of degradative enzymes, to the limited capacity for spontaneous transferred osteochondral cylinder to
and cause chondrocyte apoptosis.84,100 If repair. However, development of new the surrounding bone is required and
the integrity of the functional weight- surgical techniques has created consid- immediate postoperative rehabilitation is
bearing unit (articular cartilage, menisci, erable clinical and scientific enthusiasm dictated by the biology of the bony heal-
ligaments, muscle) is lost, either through for articular cartilage repair. Based on ing process rather than formation of new
acute injury or chronic microtrauma in the source of the cartilage repair tissue, repair cartilage tissue.
the high-impact athlete, a chondropenic these surgical techniques can generally As an alternative to the use of au-
response is initiated that can include loss be categorized into restorative and re- tologous tissue, osteochondral allografts
of articular cartilage volume and stiff- parative procedures. Restorative proce- are used for treatment of large and deep
ness, elevation of contact pressures, and dures restore articular cartilage without chondral and osteochondral lesions from
journal of orthopaedic & sports physical therapy | volume 42 | number 3 | march 2012 | 255

acute trauma, osteochondritis dissecans, Matrix-induced autologous chondrocyte tation approach should be used for every
avascular necrosis, and joint degenera- implantation is a second-generation tech- athlete following articular cartilage resto-
tion.15 This technique also provides a nique that uses a biomatrix seeded with ration (TABLE 1). The progression through
hyaline cartilage restoration by using chondrocytes and reduces surgical inva- the rehabilitation process is determined
osteochondral grafts obtained from size- siveness and risk for graft hypertrophy.14 by the biology of the repair technique,
matched donor femoral condyles to re- Characterized chondrocyte implantation characteristics of the cartilage injury,
store the cartilage defects. This technique presents a modification that optimizes clinical symptoms, radiographic findings,
can use large-cylinder grafts (Mega- hyaline cartilage regeneration through and the athlete’s sport-specific demand.
OATS technique) or so-called “shell selective expansion of chondrocyte sub- A thorough understanding of the biologi-
grafts,” which are individually shaped by populations characterized by expression cal and biomechanical factors to consider
the surgeon to the specific dimensions of gene marker profiles and phenotypic and principles of cartilage repair is im-
of the treated defect and may cover very cell characteristics that have been associ- portant. Rehabilitation of an athlete fol-
large osteochondral cartilage defects of 4 ated with formation of hyaline cartilage lowing articular cartilage repair involves
to 20 cm2. in vivo.156 These techniques produce a a multidisciplinary team approach that
hyaline-like restoration of both small and requires active and frequent communi-
Reparative Cartilage Repair Techniques large full-thickness articular cartilage le- cation. Close communication between
Marrow stimulation microfracture is the sions. A sandwich technique modification surgical and rehabilitation teams is es-
most frequently used marrow stimulation with bone grafting can be performed for sential for successful recovery and return
technique. By micropenetration of the deep chondral and osteochondral defects. to sport.
subchondral plate, this technique results In postsurgical rehabilitation it must be

in filling the cartilage defect by a blood considered that cell-based cartilage res- Factors That Influence Rehabilitation
clot that contains pluripotent marrow- toration involves a cell implantation and Patients may progress through the re-
derived mesenchymal stem cells, which stimulation phase, a cell proliferation and habilitation process at different rates,
subsequently produce a mixed fibrohya- matrix production phase, and a matrix depending on individual characteristics,
line cartilage repair tissue that contains maturation phase. lesion features, and concomitant patholo-
varying amounts of type II collagen.124 gies (TABLE 1).119 Patient age is a significant
Second-generation techniques that aim REHABILITATION predictor of outcomes after articular car-
to augment the repair tissue quality and AFTER ARTICULAR tilage repair.16,119,123 Cartilage repair in
quantity after microfracture have recent- CARTILAGE REPAIR older individuals may be slower, due to
ly been developed.173 This technique is age-dependent changes in metabolic ac-
recommended primarily for smaller car- General Concepts tivity, repair processes, and matrix syn-
R
tilage defects of up to 2 to 4 cm2 in size. ehabilitation following carti- thesis.176,184 Similarly, patients with a body
Postsurgical rehabilitation must consider lage repair surgery is a critical mass index (BMI) greater than 30 kg/m2
that cartilage repair after microfracture component of the process of re- may need slower progression during re-
occurs in 3 biologic phases: the clot for- turning the athlete to sports activity. habilitation. Although the relationship
mation phase, repair cartilage formation The focus of the rehabilitation program between BMI and cartilage repair has not
phase, and cartilage maturation phase. for all articular cartilage repair proce- been well established, individuals with
Chondrocyte-Based Cartilage Repair dures is to provide a mechanical envi- BMI greater than 30 kg/m2 have had
Techniques ACI is a 2-step procedure. ronment for the local adaptation and worse outcomes after microfracture.8,125
The first step involves an arthroscopic remodeling of the repair tissue that will Higher BMI is also a risk factor for knee
evaluation and cartilage grafting from an enable the patient to safely return to osteoarthritis98,128 and cartilage degen-
area of the joint that has limited weight the optimal level of function. The cur- eration38,44 and is related to decreased
bearing (usually the intercondylar notch). rent concepts of rehabilitation follow- cartilage volume.17,182 Impact sports can
Chondrocytes are then isolated from the ing cartilage repair in the athlete are result in tremendous biomechanical
harvested cartilage tissue and cultured based on a combination of basic science loads from repetitive joint loading asso-
with a combination of growth factors to data, the surgical techniques currently ciated with impacts, rapid deceleration,
multiply the cells for 3 to 6 weeks. Follow- available, empirical information, and a and frequent cutting and pivoting. These
ing in vitro chondrocyte expansion, the limited number of clinical studies.5,37,39, sports increase the risk of osteoarthri-
chondrocytes are implanted in a second- 45,48,52,62,69,71,72,74,76,92,107,136,147,154,155,190,191
Due tis and can be detrimental to cartilage
ary open procedure. Implantation into to the complex nature of cartilage repair repair.96,153 Kujala et al88 observed that
the defect occurs under a periosteal cover and variable defect characteristics and soccer players and weight lifters had an
that is sutured over the cartilage defect.18 comorbidities, an individualized rehabili- increased risk of developing premature

tivity and performance at the preinjury
Factors to Consider During Individualized
TABLE 1 level.
Cartilage Repair Rehabilitation
The characteristics of the cartilage
lesion must be considered in the devel-
Considerations/Specific Factors Implications
opment and implementation of reha-
Individual
bilitation interventions. Smaller lesion
Athlete’s age Slower cartilage repair with increased age
sizes typically result in better cartilage
Body mass index More gradual rehabilitation progression with body mass index greater than
repair.73,104,126 Lesion size and location, the
30 kg/m2
invasive nature of the surgical approach,
Type of sport Higher demand on repair tissue in impact sports
the specific biological healing responses,
Competitive level Competitive athletes have better outcomes
and the need to protect the repair site to
Psychological Less fear of reinjury and higher self-efficacy are associated with better outcomes
facilitate proper healing while avoiding
Lesion/defect
deleterious forces are likely to greatly
Defect size Smaller defects frequently improve faster with rehabilitation
influence the rehabilitation process. The
Repair technique More rapid rehabilitation progression with restorative techniques

amount of time between injury and sur-
Defect location Immediate weight bearing for patellofemoral defect (knee brace locked in full
gical treatment may also influence likeli-
extension)
hood of returning to sporting activities.
Duration of symptoms Longer recovery if symptoms persist longer than 12 months (deconditioning)
Athletes were 3 to 5 times more likely to
Cartilage quality Slower rehabilitation progression with generalized joint chondropenia
return to sports if surgery was performed
Concomitant injuries
within 1 year of the injury.124-126 Athletes
Concomitant procedures Modified protocols for anterior cruciate ligament reconstruction, meniscal repair,
with generalized joint chondropenia
osteotomy, etc
should be progressed slower in rehabili-
Meniscus status Slower rehabilitation progression after meniscectomy (especially lateral
tation to prevent further cartilage break-
meniscus)
down and focal cartilage defects.34,35
Concomitant injuries commonly en-
knee osteoarthritis compared to runners Both the Knee Efficacy Scale and the countered in conjunction with articular
and shooters.88 Competitive athletes have Tampa Scale of Kinesiophobia have been cartilage lesions can impact the reha-
demonstrated better outcomes than rec- shown to correlate with outcome mea- bilitation process. Medial meniscus tears
reational athletes after cartilage repair.64 sures such as the International Knee (37%) and anterior cruciate ligament
Several factors may account for the dif- Documentation Committee (IKDC) Sub- ruptures (36%) are the most common
ferences between these groups. Competi- jective Knee Form, the Knee Injury and injuries concomitant with articular car-
tive athletes are younger, more motivated Osteoarthritis Outcome Score (KOOS), tilage injuries.185 Correcting these com-
to return to sports, and often have better and the Tegner-Lysholm Knee Scoring bined injuries is crucial in the success
and earlier access to care. After surgery, Scale. Higher Tampa Scale of Kinesio- of cartilage repair.104,113 Recent studies
some patients may reduce their preinju- phobia scores are associated with failure have demonstrated that combined pro-
ry activity levels for a variety of reasons, to return to sport; conversely, higher per- cedures (anterior cruciate ligament re-
including social factors, knee problems, ceived self-efficacy is related to greater construction, high tibial osteotomy, and
and fear of reinjury.91,135,183 perceived knee function, postoperative meniscal allograft and repair) did not
Psychosocial factors have been shown sports activity levels, and knee-related adversely affect return-to-sport rate af-
to affect return to sport after knee sur- quality of life.23,26,53 Patient education, ter cartilage repair and even improved
gery and can be expected to influence verbal persuasion, and encouragement outcomes.83,125,170 However, rehabilitation
rehabilitation and athletic activity after during rehabilitation are critical for de- progression should be slower follow-
cartilage repair as well.57,178 Psychologi- velopment of the athlete’s self-efficacy. ing meniscectomy, especially of the lat-
cal factors that may affect the rehabilita- The described stepwise rehabilitation eral meniscus.3,108 Therefore, treatment
tion process include the fear of reinjury approach with criteria-based progres- guidelines may need to be modified to ac-
(kinesiophobia), coping, emotions, com- sion helps the athlete gradually develop commodate the healing characteristics of
mitment, confidence in performance, and self-confidence by successful goal setting the other biological tissues concomitantly
athlete’s control of outcome. Useful tools and task completions. Progressive sport- addressed during surgery.
that can be used to evaluate the influence specific tasks may facilitate this positive
of psychosocial factors on rehabilitation psychological feedback and development Return to Sport After Knee Articular
include the Knee Efficacy Scale and the of sport-specific self-efficacy, which may Cartilage Repair
Tampa Scale of Kinesiophobia. 90,178,179 help the athlete to return to athletic ac- Current surgical and rehabilitation tech-

niques have demonstrated encouraging
Biologic and Rehabilitation Phases
results in pain reduction and functional TABLE 2
After Articular Cartilage Repair
improvement. A primary goal for many
athletes after articular cartilage repair is
Biologic Phase Rehabilitation Phase
to return to their previous level of sports
Phase 1 Graft integration and stimulation Protection and joint activation
participation, while reducing the risk of
Phase 2 Matrix production and organization Progressive loading and functional joint restoration
reinjury. Surgical technique, patient fac-
Phase 3 Repair cartilage maturation and adaptation Activity restoration
tors, and concomitant injuries can in-
fluence the rate of return to sport after
cartilage restoration.118,119 Return to com-
petition was demonstrated in 59% to 66% Examples of Therapeutic Interventions
TABLE 3
(range, 25%-100%) of athletes after mi- and Progressions in Each Phase
crofracture, with 57% returning to their
preoperative performance level.64,118,120,126 Phase/Aims Therapeutic Intervention
Successful return to athletic activity was Phase 1

reported in 91% to 93% (range, 86%- Protection and joint activation • Preoperative counseling
94%) of athletes after OATS as early as • Cryotherapy, elevation, and compression
6 to 9 months postoperatively.61,64,83,103 • Continuous passive motion
A recent study demonstrated that 84% • Patellar mobilizations, all directions, but take care with patellofemoral repairs
of athletes returned to sport after os- • Weight-shift exercises for weight-bearing control training
teochondral allograft transplantation, • Gait training within weight-bearing restrictions
with 60% returning to their preinjury • Active-assisted heel slide exercises progressing to gradual increases in pain-free
performance level.150 Several prospective active knee ROM exercises (patellar/trochlear defects have slower progression in
studies have shown the ability to return ROM than femoral defects)
to sport in 33% to 96% of athletes after • Stationary cycle
ACI, with 60% to 80% of them return- • Stationary cycle, minimal resistance once 100° of knee flexion are achieved
ing to the same skill level.119,121,122 Irrespec- • Full active ROM exercises for ankle and hip
tive of the technique used for cartilage • Quadriceps setting exercises progressing to multi-angle isometric exercises
repair, the rate for return to sports was • Biofeedback and NMES
higher for younger and more competi- • Partial weight-bearing proprioceptive exercises (not greater than weight-bearing
tive athletes with preoperative duration restrictions)
of symptoms of less than 1 year (TABLE 1).64 • Gluteal muscle retraining
Microfracture and OATS were effective • Aquatic therapy introduced once surgical incision has healed
primarily in athletes with smaller lesions, • Rowing ergometer, no resistance (no handle)
while the ability to return to sport after • Introduce treadmill walking after full weight bearing
chondrocyte transplantation was inde- • Introduce forward lunges, forward step-ups, and lateral step-ups within safe range
pendent of lesion size. While some stud- of knee flexion after full weight bearing
ies reported decreasing function starting • Stretching program
2 years after microfracture and OATS, no Table continued on page 259.
similar functional decline was observed
for ACI.119 Postoperative participation in emphasizes the principle of individual- between cartilage repair techniques, the
sports improved the long-term functional ized technique- and athlete-specific pro- process of rehabilitation and returning
results after ACI.32,86,180 The timing of re- gression of postoperative rehabilitation. the athlete to sport after knee articular
turn to sports varies from 7 to 18 months, To ensure optimal care, the rehabilitation cartilage repair is based on, and consists
depending on the surgical technique. Av- team should be familiar with the surgical of, 3 biological healing phases: an initial
erage time to return to sport was longest and biological principles that determine protection and joint activation phase,
for ACI (18-25 months) and shortest for the protection of the postoperative joint followed by a progressive joint load-
OATS (6.5-7 months).64,119 Athletes were and apply them for each individual ath- ing and functional restoration phase,
able to return to sports 8 to 17 months lete’s unique set of circumstances. and finally an activity restoration phase
after microfracture.64,126 The biology of (TABLES 2 and 3). The development and
these cartilage repair techniques may ex- Rehabilitation Phases implementation of these treatment
plain this chronological difference, which Independent of the inherent differences guidelines reflect a criteria-based ap-

symptom monitoring and progression of
Examples of Therapeutic Interventions
TABLE 3 exercises and activity.103,174 A home exer-
and Progressions in Each Phase (continued)
cise program should be developed based
on affordability and accessibility to en-
Phase/Aims Therapeutic Intervention
sure full compliance with the exercise
Phase 2
prescription.
Progressive joint loading and • Continue quadriceps NMES until greater than 80% side-to-side quadriceps
Phase 1: Protection and Joint Activation
functional restoration strength is achieved
Factors related to the function of the knee
• Progress knee exercises to light resistance within safe ranges, with no resistance
prior to surgery are important in expected
over repaired zone
and final outcomes after surgery.29,40,85,97
• Progress from concentric to eccentric loading
Preoperative patient counseling and
• Progress from static to dynamic loading
education, along with preoperative cor-
• Gluteal, posterior hip, and lateral hip-strengthening exercises
rection of overt impairments such as
• Proprioception/balance exercise progressions: stable to unstable surfaces,
muscular imbalances or deficits, will help
uniplanar to multiplanar, double- to single-limb

to facilitate postoperative progression
• Progress proprioception exercises to more challenging surfaces and introduce
through the individual steps of the reha-
coordination and sport-specific tasks
bilitation process. In addition, gathering
• Introduce low-impact uniplanar aerobic activities and progress to moderate-
information about the athlete’s occupa-
impact uniplanar activities and then to multiplanar activities
tional and athletic demands and access to
• Introduce plyometrics in supine double-limb landing with gravity eliminated,

rehabilitation facilities and modalities is
progressing to single-limb landing with gravity eliminated and then to standing
extremely useful in designing the optimal
on foam surface
rehabilitation program.
• Continue patellar mobilizations and introduce joint mobilizations of hip, knee, and
The biology of the healing process in
tibiofibular joints
the first phase differs between restorative
• Soft tissue mobilization of the iliotibial band, patellar and quadriceps tendons,
and reparative techniques. With repara-
popliteal space, and proximal hip
tive techniques, the cells contained in the
• Continue cycle and rowing ergometer with increasing duration and gradual
defect (mesenchymal stem cells or chon-
increase in resistance
drocytes) start differentiating and pro-
• Continue aquatic therapy for general endurance

ducing a primitive, unorganized, and soft
• Continue stretching program
initial repair cartilage tissue. During this
Phase 3
phase, the soft, putty-like repair tissue is
Activity restoration (sport- • Restoration of symmetry, strength, and flexibility in lower limb
vulnerable to mechanical overload and
specific reconditioning/on-field • Loading program individualized with progression to full resistance over repaired
requires protection to avoid limited inte-
rehabilitation) defect in both closed-kinetic-chain and open-kinetic-chain activities
gration of the repair tissue to the defect
• Functional sport-specific agility training
base and surrounding normal articular
• Presport cardiovascular conditioning
cartilage.158,165 In contrast, for restorative
• Increase intensity and duration of exercise
repair techniques such as osteochondral
• Continue strengthening and flexibility exercises from phase 2
allograft or autograft, initial protection
• Education and preparation for return to sport
is aimed to allow for adequate bone-to-
Abbreviations: NMES, neuromuscular electrical stimulation; ROM, range of motion
bone healing of the implanted grafts.
Because these techniques rely on bony
proach based on scientific research of which demands careful attention to its healing as opposed to cartilage growth,
articular cartilage repair healing con- specific healing constraints. progression of weight bearing is usually
straints, knee complex biomechanics, The therapist must monitor any pro- faster with restorative techniques. High
neuromuscular physiology, and general gressions in exercise and activity to en- compressive and shear stresses during
sport-specific tasks. Thus, progression sure that symptoms are not increased. the first rehabilitation phase can decrease
through rehabilitation should be based Pain and swelling are primary indicators chondrocyte metabolic rate, thereby neg-
on criteria rather than fixed time lines that rehabilitation is progressing too rap- atively affect the process of repair tissue
(TABLE 4). However, the implementation idly and overloading the healing tissue. 9 and integration for both reparative and
of discretely different surgical techniques Grading of the effusion with the modi- restorative techniques.127 In contrast, low
can influence the biomechanical and fied stroke test and soreness rules pro- mechanical forces may promote carti-
physiological function of the cartilage, vide clinicians with reliable methods for lage formation and nutrition, as well as

applied clinical biomechanics and an ap-
Weight-Bearing Guidelines and Criteria for
TABLE 4 preciation of forces and loads exerted on
Progression After Articular Cartilage Repair
the developing graft tissue are essential
Phase 1. Weight-Bearing Guidelines
for designing the appropriate rehabilita-
• Femoral defects
tion program during this phase. If con-
- Restorative techniques (OATS/allograft): touch-down loading for 2 wk, then progress to full weight bearing
comitant surgical procedures, such as
by 4 to 6 wk
anterior cruciate ligament reconstruc-
- Reparative techniques (microfracture/ACI): touch-down loading for 2 wk, then progress by 25% body weight per wk
tion, meniscus repair, or osteotomy, are
• Patellar/trochlear defects
performed, the rehabilitation program
- Immediate weight bearing with brace locked in 0° to 10° of knee flexion
should be revised on an individual ba-
Progression Criteria to Go from Phase 1 to Phase 2
sis by incorporating the requirements of
• Full passive ROM equal to the nonoperated knee
the concomitant procedure in conjunc-
• Minimal or absent pain (VAS less than 3/10)
tion with the articular cartilage repair
requirements.
• Minimal or no effusion (grade 0 or 1+)

• Recovery of muscular activation
Pain and Effusion After knee surgery,
• Recovery of normal gait cycle (equal stride length and stance time between limbs, no limp)
patients frequently have complaints of
Progression Criteria to Go from Phase 2 to Phase 3
pain and knee joint effusion. Decreased
• Full and painless ROM
voluntary activation of the quadriceps
• No or minimal pain (VAS less than 3/10)
and altered knee joint mechanics have
• No or minimal effusion (grade 0 or 1+)

been associated with experimentally in-
• Maximum peak torque difference of less than 20% between limbs on isokinetic test
duced effusion.137,138,168 The reduction of
• Hop performance difference of less than 10% between limbs
pain and knee joint effusion is a primary
• Self-report outcomes greater than 90%
goal initially after cartilage repair, with
• Ability to run on a treadmill at 8 km/h for more than 10 min
cryotherapy being an effective modal-
• MRI evaluation of the repaired cartilage to evaluate repair tissue
ity that clinicians and patients can read-
ily use. The application of cryotherapy
Abbreviations: ACI, autologous chondrocyte implantation; MRI, magnetic resonance imaging; OATS,
osteochondral autograft transplantation system; ROM, range of motion; VAS, visual analog scale (FIGURE 1), compression, and elevation is
important to lower tissue temperature,
slow metabolism, decrease secondary

bone-to-bone healing.7,71,92 In the early to directly support the frequency, inten- hypoxic injury, and reduce edema forma-
postoperative phase, the challenge is to sity, type, and timing of exercises and tion.102 A meta-analysis by Raynor et al146
construct an individualized rehabilitation other therapeutic modalities for articu- demonstrated that patients who received
program that provides appropriate stim- lar cartilage repair rehabilitation is lim- cryotherapy had less postoperative pain
ulation, while avoiding mechanical load- ited.32,62,76,119,147,180,190 The incorporation but no improvement in early ROM after
ing that may be detrimental to the repair of therapeutic modalities and exercises anterior cruciate ligament reconstruc-
tissue. Due to the differences introduced into an articular cartilage repair reha- tion. The use of compression wraps or a
by different cartilage repair techniques, bilitation program is best conceptual- sleeve may also assist in the reduction of
lesion characteristics, and concomitant ized in terms of optimizing joint stress, effusion.
procedures, the initial limit and progres- as opposed to the complete avoidance of Pain and particularly joint effusion
sion of weight-bearing activities should specific ranges of movement. This can following exercise should be avoided, as
be individually determined by the sur- be achieved through the selection, in- these may lead to quadriceps inhibition
gical and rehabilitation teams for each troduction, and progression of exercises and its negative effect on neuromuscular
athlete. Consequently, the duration and that are appropriate for the repair tis- joint control, joint biomechanics, and re-
activities of the protection phase may be sue status, size, and location. The repair sultant increase in joint reaction force in
variable. The focus during the first phase site is most vulnerable during the initial the area of the cartilage repair.97 While
of an articular cartilage repair program phase after articular cartilage repair, and mild to trace joint effusion may be nor-
should be on reducing pain and effusion, a graded rehabilitation program that mal during the first 4 to 6 weeks after
monitoring weight-bearing restrictions, incorporates preoperative counseling, articular cartilage repair, extensive ef-
and addressing impaired range of mo- progressive weight bearing, and con- forts should be made to limit and reduce
tion (ROM), muscle performance, and trolled exercise is recommended during effusion by avoiding overly aggressive
neuromuscular control.62,72,78,147 the initial protection and joint activation rehabilitation. Recurrent joint effusion
The scientific and clinical evidence phase. A thorough understanding of the indicates overload of the repair cartilage

and premature progression during reha-
bilitation and should be avoided.
Weight-Bearing Restrictions Load-in-
duced formation and remodeling of the
articular repair tissue is an important
component of rehabilitation that starts
in phase 1. The scientific and clinical evi- FIGURE 1. Cryotherapy.
dence to determine the optimal timing
of return to full weight bearing following
articular cartilage repair is increasing but
varies across different types of articular FIGURE 3. Continuous passive motion.
cartilage repair procedures.32,58,119,125,147,170
In addition to the surgical technique, defects are large, kissing, or if there is an
the amount of initial weight bearing and active quadriceps extension lag.
progression should be individually de- Impaired ROM Restoration of normal

termined based on articular lesion and ROM presents a critical initial step to-
patient characteristics and associated ward normalization of joint kinematics.
surgical procedures (TABLE 4). Cell-based Repetitive dynamic movement through
articular cartilage repair procedures have FIGURE 2. Weight-bearing progression. the available ROM provides mechani-
historically included the longest periods cal stimulation to chondrocytes and

of weight-bearing restrictions.62 Newly technique is also useful for controlling increases synovial fluid flow and graft
emerging research indicates that it is pos- weight-shift exercises and for correction nutrition.74,190 Continuous passive mo-
sible to accelerate weight-bearing loads of body posture and any residual un- tion (CPM) is recommended immedi-
in certain patient populations and have loading of the involved limb later in the ately postoperatively and is a standard
good clinical and functional outcomes rehabilitation process. Because normal inclusion in articular cartilage repair re-
without jeopardizing the graft.37,190 While arthrokinematics during dynamic ath- habilitation in many centers (FIGURE 3).72
initial guidelines emphasized the impor- letic activities involve rolling, spinning, In addition to its effect on ROM, CPM is
tance of minimizing shear stress in the and gliding motions of the knee joint, reported to increase the quality of chon-
early stages of rehabilitation after car- early restoration of joint kinematics is an dral repair tissue and stimulate the me-
tilage repair, recent research has shown important goal of the first rehabilitation tabolism of proteoglycan (PRG4).4,136,154,155
that moderate dynamic compression phase. Restoration of normal arthrokine- The current recommendation for the use
and low shear loading are beneficial to matics will also help maintain repair car- of CPM is based on basic science, empiri-
extracellular matrix biosynthesis, chon- tilage homeostasis in the later stages of cal practice, case series, and disease-ori-
drocyte proliferation, and repair tissue rehabilitation.48,52,92 Gait training focuses entated evidence.72 A retrospective study
maturation, while static compression on crutch walking to minimize soft tis- by Rodrigo et al151 indicated that follow-
and immobilization are associated with sue restrictions (especially tightness in ing microfracture surgery, patients who
adverse effects.7,71,92 However, high shear hamstrings, gastrocnemius, and soleus used a CPM device were more likely to
stress may lead to mechanical failure muscles) and increase load acceptance have improvement in cartilage healing
of articular cartilage repair in the early on the involved limb through controlled on second-look arthroscopy compared
postoperative rehabilitation phase; it weight shifting. to those who did not use a CPM device.
is therefore necessary to implement a Aquatic therapy can start once the sur- Based on available evidence, CPM use is
graded increase of joint stresses and gical incision has healed and the patient recommended for 4 to 6 weeks postoper-
loading. Weight-bearing status should is able to safely transfer in and out of the atively to stimulate the cellular response
be based on the location of the repair on pool. Water depth used for the exercises in the implanted graft and neomatrix
the tibiofemoral and patellofemoral joint should reflect the current weight-bearing production.151,154,189 Once again, individu-
surfaces. It is important to recognize that status of the individual.65 Although no ev- alized restoration of ROM and CPM use
patients do not reliably maintain their idence-based consensus currently exists should be based on articular defect and
weight-bearing restrictions. The accu- on the use of postoperative bracing after patient characteristics. Following patel-
racy of weight-bearing application can knee articular cartilage repair, a brace lofemoral chondral repairs, the progres-
be assessed, taught, and reinforced with locked in full extension is commonly sion of ROM with CPM should be slower
patients both presurgery and postsurgery, recommended for patellofemoral repairs than that following tibiofemoral chondral
using 2 identical scales (FIGURE 2).62 This for the first 4 to 6 weeks, especially if the repairs, because of the high joint reaction

stress in the patellofemoral joint during
passive knee flexion ROM.120 CPM is not
consistently used across cartilage repair
centers and is often not available to pa-
tients. Some studies have indicated that
for patients with small, isolated defects of
the femoral condyle and intact surround-
ing cartilage, CPM may be replaced with
graded weight bearing and active ROM.
However, these studies had small cohorts
or were case reports with a low level of
evidence, the outcomes of which can-
not be generally extrapolated.5,107 Where
CPM is not available, it may be substi-
FIGURE 4. Stationary cycling.

tuted by 500 active-assisted heel slides,
performed 3 times per day, with the same stand, walk, or run, and difficulty return-
ROM progressions and goals indicated ing to previous levels of activity.112,140,159,161
for CPM.62 Stationary cycling with par- Additionally, increases in patellofemoral
tial revolutions can be initiated to pro- contact pressure have been documented
mote ROM. Once knee flexion ROM is in knees with quadriceps or patellar ten-
95° to 100°, full-revolution cycling with don adhesions.2 Therefore, the use of pa-
minimal resistance can be introduced tellar mobilizations should be a part of
(FIGURE 4).62 ROM exercises should prog- any early postoperative treatment. In the FIGURE 5. Schematic drawing illustrating the unsafe
ress through a controlled increase in early postoperative period, gentle patel- range of motion during which the cartilage defect
articulates with the opposing joint surface (from
motion through passive, active-assisted, lar mobilizations in all directions 4 to 6
Mithoefer et al124).
and then active movements. Active ROM times per day are important to prevent
exercises can be progressed to light resis- adhesions and arthrofibrosis (FIGURE 6).28
tance in safe ranges, while simultane- Impaired Muscle Performance Follow- side percent deficits in the MVIC for the
ously maintaining no resistance over the ing the surgical trauma, early muscular knee extensor and flexor muscles are then
repaired area. Safe ranges will be dictat- activation is an essential component of calculated.
ed by the articulation surfaces, contact restoring muscular joint control and Quadriceps strength deficits are fre-
area, and size and location of the graft normal arthrokinematics. The use of iso- quently observed after knee surgery and
(FIGURE 5). For example, as the posterior metric muscle dynamometry allows the may persist.25,29,138 Isometric quadriceps
aspect of the medial femoral condyle con- clinician to track the progress of muscle setting exercises are performed and pro-
tacts the tibia between 90° and 120° of performance throughout the recovery gressed from full knee extension posi-
knee flexion, light resistance in the range period. Isometric testing, if the location to multi-angle exercises. In patients
of 0° to 80° of knee flexion may be ap- tion and size of the cartilage repair are with gross quadriceps strength deficits,
propriate if the articular defect was on known, may be performed early after sur- neuromuscular electrical stimulation
the posterior aspect of the femoral con- gery to avoid testing positions that may (NMES) may help to promote quadri-
dyle.76 Several articles provide detailed increase joint stress and thereby damage ceps strength gains. NMES can be in-
information on the clinical biomechan- the cartilage repair. This testing consists troduced early during the postoperative
ics of the tibiofemoral and patellofemoral of maximal isometric voluntary contrac- period and is a valuable adjunct to the
joints.39,59,114 tion (MVIC) of the quadriceps and ham- program, especially when voluntary con-
Knee motion loss can be a disabling strings. To produce an MVIC, patients are trol of the quadriceps mechanism is still
complication. Arthrofibrosis is a com- familiarized with the testing procedure impaired (FIGURE 7). The use of NMES
mon cause of knee motion loss after and provided with standardized verbal combined with exercise has been shown
knee surgery.142,163 Patients with limited encouragement from the therapist and to be effective in treating quadriceps
knee motion due to arthrofibrosis often visual feedback from the dynamometer’s strength deficits after anterior cruciate
complain of anterior knee pain, swell- real-time visual display. Patients perform ligament reconstruction.82,192 NMES can
ing after prolonged positions or activity, three 5-second MVICs, each separated by improve quadriceps strength if applied
quadriceps weakness, and joint stiffness, a 2-minute interval to allow the muscles at a high-intensity setting early in the
which can result in decreased tolerance to to rest and to avoid fatigue. The side-to- rehabilitation process.30,99,166 Quadriceps

sion (grade 0 or 1+), ability to perform
active straight leg raises without a quad-
riceps extension lag, side-to-side deficits
of quadriceps strength of less than 30%,
and ambulation with equal stride length
and stance time between limbs and full
knee extension at heel strike. Once the
objectives of the protection phase have
been achieved, the patient may be pro-
FIGURE 8. Isokinetic muscle strength test. gressed to the second phase of cartilage
FIGURE 6. Patellar mobilization.
repair rehabilitation.
to initiating these functional exercises, Phase 2: Progressive Joint Loading and
patients need to demonstrate adequate Functional Restoration The focus of
strength and neuromuscular control to the second phase is to begin controlled
properly perform the exercises. Proper gradual increase of the mechanical stress
technique must be maintained through- on the primary repair tissue to stimulate
out the exercises. cellular metabolism leading to produc-
Impaired Neuromuscular Control In tion of proteoglycans and collagen de-
addition to weight bearing, CPM, and position.171 This controlled stimulus to
ROM guidance, rehabilitation guidelines the healing cartilage is gradually applied

should provide information regarding while preventing excessive overloading
neuromuscular control and re-educa- that might damage the repair. This allows
FIGURE 7. Neuromuscular electrical stimulation. tion. Alterations in neuromuscular con- the cartilage repair tissue to strengthen
trol may influence clinical outcomes.75,149 and become more resilient to increas-
strength deficits should be within 30% Knee surgery results in proprioceptive ing mechanical stress and more complex
of the contralateral limb with isometric deficits that should be addressed at the joint loading patterns, including both
dynamometry to progress to phase 2 of earliest postoperative opportunity.69 Pro- compressive and shear forces. This phase
rehabilitation. prioceptive training can be initiated in of rehabilitation is, therefore, designed to
Once full weight bearing has been the early phase of rehabilitation within maintain ROM and flexibility, while re-
restored, weight-bearing (closed-chain) the patient’s weight-bearing restrictions. storing neuromuscular control and ini-
exercises can be introduced within This may often require adaptation of ex- tiating simple sport-specific movement
safe ranges, as dictated by the repair ercises to match the weight-bearing re- patterns. The clinical focus for the second
location and size. During this phase, strictions and can be progressed along rehabilitation phase is directed toward
weight-bearing exercises must be gradu- with increased weight-bearing status. addressing altered joint loading and im-
ally introduced to facilitate healing and Impairments of the gluteal muscles paired lower extremity muscle perfor-
to reduce postsurgical complications. can influence tibiofemoral and patel- mance, neuromuscular control/dynamic
During weight-bearing movements, all lofemoral joint biomechanics. Gluteus balance, and sport-specific movement
condylar surfaces bear weight through maximus and medius play an important patterns while maintaining full active
the arc of knee motion.177 With weight- role in the neuromuscular control of ROM without pain, effusion, or locking.
bearing movements, tibiofemoral joint dynamic valgus of the knee and, conse- Impaired Muscle Performance Emphasis
contact forces progressively increase with quently, normal posture and gait pat- is placed on full restoration of strength
knee flexion to reach 2.7 to 4 times body terns.10,144,164 Therefore, gluteal muscle and balance to address residual deficien-
weight at 90° of flexion. Similarly, patel- retraining is an important component of cies. Strength deficits in the quadriceps
lofemoral contact forces progressively articular cartilage repair rehabilitation, and hamstrings, as well as quadriceps-to-
increase with knee flexion to reach 6.5 to especially when patients have altered hamstrings strength imbalance, should
9 times body weight at 90° of flexion.1,42 lower extremity kinematics.145 be actively addressed. Testing can be
Patients can safely begin to incorporate Milestones for Phase 1 Milestone crite- performed with an isokinetic device
weight-bearing exercises, such as forward ria for advancement to phase 2 (TABLE 3) (FIGURE 8) after adequate practice is al-
lunges and forward and lateral step-ups, include full passive extension and flexion lowed to ensure maximal effort. After
from 0° to 60° of knee flexion as long as ROM equal to the nonoperated knee, warm-up exercises, the patient is asked
substantial compressive loads to the heal- minimal to no pain (less than 3/10 on a to perform 4 maximal concentric repeti-
ing articular cartilage do not occur. Prior visual analog scale), minimal to no effu- tions (ROM from 0° to 90°) at a speed

of 90°/s. A side-to-side deficit in quadri- ercises, stable to unstable surfaces, slow
ceps strength greater than 20% is an in- to fast speeds, unidirectional to multi-
dicator of poor quadriceps strength97,162 directional movements, and simple to
and should continue to be treated with complex skills (FIGURE 9).79,155,156,158 Balance
NMES.167 Electrical muscle stimulation activities are progressed when patients
and/or biofeedback should also be con- are able to maintain their limb, joint, and
tinued if significant atrophy or muscle body position while reacting and adapt-
inhibition is noted.147 By the end of phase ing to changes in loads and forces.133
2 and before proceeding to phase 3 of the Myer et al133 recommended that patients
rehabilitation, patients should demon- be able to maintain postural control for at
strate less than 20% side-to-side strength least 5 seconds during a single-limb squat
deficits for knee flexion and extension performed at 60° of knee flexion. The in-
when tested at 90°/s. ability to maintain postural control may
For patients who continue to exhibit amplify limb-to-limb strength deficits
strength deficits, the use of non–weight- during functional tasks.

bearing (open-chain) exercises has been After adequate strength and postural
shown to be effective in enhancing mus- control have been achieved, the use of
cle strength after knee surgery.21,111,116,172,175 perturbation devices is indicated to fur-
With non–weight-bearing movements, ther enhance neuromuscular control.
tibiofemoral joint compressive forces Perturbation of the support surface by

decrease with knee flexion.186,193 Patel- the rehabilitation specialist is performed
lofemoral contact forces progressively to alter forces and torques in multiple
increase with knee flexion once loads planes in a systematic progression.46
exceed 25 N.27 Proper technique must be FIGURE 9. Proprioceptive exercises. The patient’s objective is to either resist
maintained throughout the performance the force applied by the therapist or to
of exercises and no increase in symptoms posterior hip, and lateral hip strength re-establish a balance posture after the
should occur. and control is important if any dynamic perturbation was applied. A progression
Athletes must be able to decelerate valgus or excessive lateral compartment in difficulty, similar to the one described
their body or a body segment rapidly to loading at the knee is recognized. Pa- above for balance activities, can be fol-
successfully complete sports maneuvers. tients should demonstrate no more than lowed. Subsequent sessions progress
During deceleration, the lower extremity a 15% side-to-side deficit in hip abduc- from expected to random directions and
muscles absorb mechanical work while tion strength at the end of phase 2. timing of the perturbation, increasing
lengthening.93 Eccentric muscle train- Impaired Neuromuscular Control/Dy- intensity and magnitude of the forces,
ing is effective in enhancing quadriceps namic Balance In the second phase, the and decreasing verbal cues. Progression
strength and hop performance after ante- restoration of neuromuscular control is of perturbations is individualized based
rior cruciate ligament reconstruction.54,55 critical to optimize joint function and re- on the patient’s ability to apply appro-
Submaximal eccentric muscle-loading turn to athletic activity. The entire kinetic priate directional and counter-resistive
exercises may assist in overcoming force chain of the lower extremity (hip, thigh, force and muscle activation patterns and
attenuation impairments.93 We recom- and calf ) and trunk musculature should reduction in loss of balance.
mend that athletes demonstrate peak be addressed. Proprioception, dynamic Having the patient perform various
eccentric torque symmetry within 20% joint stability, reactive neuromuscular functional tasks while standing on an un-
of the opposite side when tested at 90°/s. control, and functional motor patterns stable surface should follow and should
Deficits in hip abduction torques have are affected by knee injury.11,13,20,95,188 The progress by increasing the difficulty of the
been associated with excessive lower ex- role of rehabilitation is to enhance the tasks. Providing verbal, tactile, and visual
tremity dynamic valgus and anterior function of the sensorimotor system to cues is indicated initially but should be
cruciate ligament injuries in female ath- integrate and process mechanoreceptor strategically and systematically removed
letes.51,68 Hip strength asymmetries in information, creating synchronized and when the patient is able to adapt and
athletes may also result in suboptimal synergistic motor responses that reduce react to the perturbation. A rehabilita-
performance on the playing field and microtrauma and recurrent injury on tion program augmented with perturba-
have been linked to an increased risk of joint structures.57,96,155 Balance activities tion training has been shown to result in
second anterior cruciate ligament inju- should progress from bilateral to unilat- improvements in physical performance
ry.12,68,133,139,160 Restoring optimal gluteal, eral stance, eyes-open to eyes-closed ex- measures, self-report outcomes, and bio-

mechanical deficits.22,41,46,66 Perturbation ble-limb landing to initially minimize the jog progression program on a treadmill
training is an effective training approach stress applied to the joint. The emphasis to augment unilateral limb strengthen-
to improve dynamic knee stability in should be on achieving equal load sharing and force generation and attenuation
athletes and patients following anterior ing across the entire joint surface and during the dynamic component of run-
cruciate ligament injury. Neuromuscu- between limbs. If poor technique is ex- ning.103 The running progression begins
lar and proprioceptive re-education has hibited by the athlete, such as excessive with alternating jogging and walking for
important implications for dynamic joint internal rotation of the femur, external a distance of 3.2 km. The ratio of run-
alignment and has been shown to play rotation of the tibiofemoral joint, exces- to-walk distance is initially gradually
an important role in preventing injury or sive foot pronation, or excessive dynamic increased before increasing the running
reinjury.105,132 knee valgus, it is critical to address the distance to the patient’s preferred or re-
Altered Joint Loading Patients who de- movement dysfunction at this point in quired amount.
sire to return to a high-level sport or an time, prior to introducing single-limb Maintenance of ROM/Flexibility It is
activity that requires jumping and land- landing or exercises against gravity. Once important to continue to include man-
ing should initiate plyometric activities the athlete demonstrates proper tech- ual therapy in this phase of treatment.
during this phase. While the effects of nique and is able to tolerate the volume Joint mobilization of the patella, hip,
plyometric training on patients recover- and intensity prescribed without pain or and tibiofemoral and tibiofibular joints
ing from knee injuries, especially after swelling, plyometrics can be performed may be indicated at this time. Deyle et
articular cartilage repair, are unknown, using a single limb but in a supine, al33 utilized a combined rehabilitation
it may be a critical training method to gravity-eliminated position. Standing program of manual therapy techniques
safely return athletes to full sports par- plyometrics should be introduced and and standardized knee exercises to im-
ticipation.24,60,70,81,87,94,110,120,130,131 Because performed initially on foam or other for- prove 6-minute walk time and self-report
of the considerable loads and speeds ap- giving/compliant surfaces to minimize scores in patients with knee osteoarthri-
plied to the healing joint with plyometric the applied and functional forces being tis. Soft tissue mobilization of the iliotibi-
training, patients should first demon- generated. Plyometric exercises can effec- al band, patellar and quadriceps tendons,
strate the ability to tolerate the demands tively restore neuromuscular joint con- popliteal space, and the hip region should
of daily activities without pain or swell- trol to optimize joint biomechanics and be included. A randomized controlled
ing.24 Clinicians must be diligent in mon- load distribution under higher impact trial in patients with knee osteoarthritis
itoring the patient’s response to training, conditions, with the goal of protecting has demonstrated improvements in self-
using effusion grading and soreness rules. the repair cartilage from overload. report scores, pain, ROM, and functional
Additionally, the clinician should stress Impaired Sport-Specific Movement Pat- performance after an 8-week program of
that patients maintain proper technique terns The resumption of low-impact massage therapy.141 The patient should
throughout the plyometric training. It activities is recommended based on the be educated in monitoring joint stiffness
is critical to include the work-rest time athlete’s preferred sport and the surgi- and instructed to mobilize joints and soft
ratios (1:1 or 1:2) recommended during cal approach. Low-load activities pro- tissues and to actively treat any acute ef-
this phase of rehabilitation, and plyomet- duce tibiofemoral joint loads between fusion as a result of the introduction of
ric training should not be performed on 1.2 times body weight with cycling and new therapeutic activities.
successive days.24 Volume, intensity, du- 6 times body weight with stair descent,89 Milestones for Progression to Phase 3 The
ration, and frequency of training should and patellofemoral joint loads between athlete can progress to on-field rehabili-
not be progressed if patients exhibit poor 0.5 times body weight with level walk- tation when the following criteria are
technique, fatigue, or are unsafe during ing and 5.7 times body weight with stair met: full ROM, minimal or no pain (vi-
the performance of the task. Chmielewski descent.157 Low-load activities, such as sual analog scale less than 3/10), minimal
et al24 recommended that volume be in- skating, rollerblading, and cross-country or no effusion (grade 0 or 1+), less than
creased prior to increasing the intensity skiing, can be initiated when the patient a 20% side-to-side deficit in maximal
or frequency of exercise or decreasing has full knee ROM, no pain or effusion peak torque tested with an isokinetic de-
rest time. The use of orthotics, bracing, with weight-bearing activities, and suf- vice,167,187 less than 10% side-to-side defi-
and taping can be helpful during this ficient healing of the repaired cartilage. cits on 4 single-leg hop tests (single hop
phase, potentially to reduce the compres- Subsequent gradual progression to mod- for distance, crossover hop for distance,
sive and shear loads in the compartment erate-impact activities ( jogging) occurs triple hop for distance, and 6-meter
where the repair has occurred. when the athlete has side-to-side quad- timed hop),47,67,134,148 and the ability to run
We recommend that plyometric ex- riceps strength greater than 80% and on a treadmill at 8 km/h for more than 10
ercises be performed first in a supine ambulates with a normal gait pattern. minutes.32,133,152,174 Additionally, patients
position (gravity eliminated), using dou- Patients are permitted to begin a walk/ should demonstrate scores greater than

of the on-field rehabilitation.
TABLE 5 On-Field Phases On-field rehabilitation is the final and
important component of the return-to-
sport program following cartilage repair.
Stage Test Rehabilitative Exercises
During this phase, further organization
1 • Aerobic fitness test • Gaining confidence with the environment and the ground
and maturation of the cartilage repair
• Walking in a straight line without shoes
tissue is expected through adaptation
• Circular walking
to the increasingly more demanding
• Slow running in a straight line on rehabilitation field
joint stresses associated with impact
• Exercises of mobilization and coordination
and pivoting activities. Adaptations in-
• Sand exercises (walking, balancing without jumping)
clude increased rigidity of the matrix
2 • Circular running
due to further proteoglycan deposition
• Skipping exercises
and cross-linking, collagen production,
• Increasing speed of running
and cellular orientation and organiza-
• Light jumps and landings on the sand

tion within the neocartilage tissue.176,184
• Advanced proprioceptive exercises
Gradually increasing impact and sport-
• Aerobic conditioning
specific movement patterns during this
3 • Countermovement jump • Running at different speeds with slow changes of direction
phase is intended to prepare the athlete
• Squat jump • Slow decelerations
to return to the high mechanical stresses
• Skips (different patterns)

associated with sports, without overload-
• Jumps and landings on the field
ing the repair tissue, which could poten-
tially lead to repair tissue deterioration.
4 • Running with fast changes of direction
Currently, it is not known how the repair
• Decelerations
tissue quality affects joint function and
• Technical and sport-specific exercises
ability to return to sport; however, lim-
• Jumps and landings with rotations
ited repair tissue volume has been associ-
ated with a higher failure rate.126
• Anaerobic-threshold running for 15 min
The final phase is to develop a pro-
5 • Aerobic fitness test • Sprinting and fast changes of direction

gram that allows for continued recov-
• Countermovement jump • High-intensity exercises in playing situations
ery while progressively replicating and
• Squat jump • Aerobic conditioning
simulating the complex interaction of
• Anaerobic-threshold running for 20 min
tasks during sports.31,101 Rehabilitation
specialists must understand the needs
90% on the Knee Outcome Survey ac- lier, cartilage-sensitive MRI evaluation of the athlete and design an appropriate
tivities of daily living scale (KOS-ADLS) of the graft or repair tissue is routinely program to eventually meet the biome-
and the global rating scale of perceived recommended to determine the status chanical and physiological demands of
function.46,67 Athletes not meeting these of the graft before advancing to on-field their sport. The goal is to progressively
criteria should continue rehabilitation rehabilitation and high-impact athletic challenge the athlete to allow for full
with a focus on the areas in which they activities. MRI is helpful to evaluate the clearance for integration back to physi-
did not achieve the milestones. By using volume of the repair cartilage and can cal or sporting activities, while minimiz-
objective criteria rather than fixed time help rule out significant graft hypertro- ing the risk of reinjury. The primary goal
tables, this strategy for progression to phy or subchondral bone marrow edema, of this last phase of rehabilitation is to
on-field rehabilitation follows one of the which may indicate risk of graft failure address any remaining impairments in
main principles of sports rehabilitation.90 or graft delamination. Increased risk for muscle power, metabolic capacity, and
As the athlete moves to the next phase traumatic graft delamination has been sport-specific movement patterns, as well
of the treatment, on-field rehabilitation, observed in high-impact athletes with as diminished athletic performance.
open and continued communication graft hypertrophy after first-generation The on-field rehabilitation phase
among the rehabilitation team, coaches, chondrocyte implantation.122 Newer MRI should follow a continuum, building on
and training staff is crucial to achieve the techniques, such as d-GEMRIC and T2 activities used to simulate athletic move-
optimal outcome for the athlete. mapping, also provide qualitative infor- ment patterns that were started during
Phase 3: Activity Restoration In addi- mation about the repair tissue that can the late stages of the second phase of re-
tion to the physical criteria listed ear- help with the individualized progression habilitation and were taking place in the

FIGURE 10. Gradually increasing on-field rehabilitation exercises. Global coordination (A), skipping exercises (B and C), sport-specific exercises (D), and high-intensity exercises
simulating playing situations (E).
gym and in the pool. The last phase of re- the initiation of on-field rehabilitation, recommend that athletes perform the ex-
habilitation takes place on a specialized the patient performs an aerobic fitness ercises at or below their aerobic thresh-
rehabilitation field under the supervision test to identify aerobic and anaerobic old. Athletes are progressed to the next
of rehabilitation specialists. On-field re- thresholds used to personalize the in- phase, when they can perform these drills
habilitation is designed as a sport-specific tensity of each training session based on without pain, swelling, or apprehension.
progression of exercises that allows grad- metabolic training loads. Aerobic and Stage 2. At this stage, circular run-
ual functional recovery of sport-specific anaerobic thresholds are assessed by ning and skipping exercises, advanced
skills, starting with in-line running and an incremental treadmill-running test, proprioception exercises, alternating
jumping and progressing to acceleration starting at 7 km/h, increasing by an in- running and stopping, and lateral slides/
and deceleration drills, pivoting and cut- crement of 2 km/h every 3 minutes until shuffles are introduced (FIGURE 10B). The
ting maneuvers at increasing speeds, and capillary blood lactate concentrations patient also performs light jumps and
incorporation of sport-specific equip- exceed 4 mmol/L.31,152 Aerobic threshold soft landing on sand. Proper technique
ment and movement patterns. is identified by a capillary blood lactate and optimal trunk and lower-limb align-
On-field rehabilitation should consist concentration of 2 mmol/L.50 The heart ment are emphasized through all exer-
of specific exercises and drills, lasting ap- rate that corresponds with the aerobic cises, with particular attention to the
proximately 90 minutes, performed be- threshold is identified as the aerobic use of adequate hip and knee flexion and
tween 3 and 5 times a week (depending threshold training heart rate. Anaerobic controlling for excessive knee abduction.
on the athlete’s activity level) for at least threshold is identified by capillary blood Additionally, the metabolic requirements
8 weeks. A significant aspect of on-field lactate concentration of 4 mmol/L.50 are increased, with athletes performing
rehabilitation is dedicated to aerobic con- The heart rate that corresponds with the tasks between their aerobic and anaero-
ditioning and sport-specific fitness exer- anaerobic threshold is identified as the bic thresholds. Aerobic conditioning is
cises to facilitate the readiness for return anaerobic threshold training heart rate. performed at the aerobic threshold for
to competition at the preinjury level and During each training session, athletes 10 to 15 minutes, and anaerobic condi-
to reduce the risk of reinjury after suc- wear a heart rate monitor to control the tioning is performed for less than 10%
cessful return. Progression is always metabolic intensity of the training. Peri- of the training time. To progress to the
criteria-based, requiring the absence of odic reassessment of metabolic training next phase, the athlete must demonstrate
pain and swelling and the maintenance load is performed to adjust the metabolic proper technique during all drills per-
of full ROM with the increasing activity intensity to improve cardiorespiratory fit- formed at near full speed, without pain,
demands. During this phase, the athlete ness for return to sport. swelling, or apprehension.
should continue strengthening and flex- Stage 1. In the first few sessions, the Stage 3. The aerobic fitness test is re-
ibility exercises in the gym. A recent co- patient walks along a straight line to peated to establish new aerobic and an-
hort study demonstrated that return to gain confidence with the training envi- aerobic thresholds. Additionally, squat
sport after arthroscopic ACI, accelerated ronment, rehabilitation field, and the and countermovement jump tests are
by an on-field rehabilitation program, ground. Initially, a more compliant sur- performed to measure jumping per-
was achieved in 81% of cases with an av- face, such as sand, is used as an effec- formance and lower extremity power.
erage time of return of 10.6 months. 32 tive low-impact method for improving If available, the tests can be performed
On-field Rehabilitation Stages On-field strength and proprioception. Once the on a platform connected to a digital
rehabilitation is divided into 5 stages athlete has become familiar with the timer that records flight and contact
(TABLE 5), each characterized by well- training environment, slow running in a time.109 The athlete performs the squat
defined, progressive, sport-specific exer- straight line is initiated, as well as global jump by jumping from a semisquat po-
cises performed outdoors on a grass field coordination exercises (agility drills) sition without countermovement, and
or indoors on a synthetic field. Prior to (FIGURE 10A). Throughout this phase, we the countermovement jump by allow-

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@ MORE INFORMATION
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2009;39:845-849. http://dx.doi.org/10.2519/ 1998;6:400-409. http://dx.doi.org/10.1053/ WWW.JOSPT.ORG

Current Concepts For Rehabilitation and Return To Sport After Knee Articular Cartilage Repair in The Athlete

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[ clinical commentary ]

Current Concepts for Rehabilitation and

42-03 Mithoefer.indd 254 2/22/2012 6:23:28 PM

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subchondral plate, this technique results In postsurgical rehabilitation it must be

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Repair technique More rapid rehabilitation progression with restorative techniques

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Successful return to athletic activity was Phase 1

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uniplanar to multiplanar, double- to single-limb

• Introduce plyometrics in supine double-limb landing with gravity eliminated,

• Continue aquatic therapy for general endurance

42-03 Mithoefer.indd 259 2/22/2012 6:23:33 PM

• Minimal or no effusion (grade 0 or 1+)

• No or minimal effusion (grade 0 or 1+)

slow metabolism, decrease secondary

42-03 Mithoefer.indd 260 2/22/2012 6:23:34 PM

progression should be individually de- Impaired ROM Restoration of normal

historically included the longest periods cal stimulation to chondrocytes and

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FIGURE 4. Stationary cycling.

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ROM guidance, rehabilitation guidelines the healing cartilage is gradually applied

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strength deficits, the use of non–weight- during functional tasks.

tibiofemoral joint compressive forces Perturbation of the support surface by

42-03 Mithoefer.indd 264 2/22/2012 6:23:41 PM

42-03 Mithoefer.indd 265 2/22/2012 6:23:42 PM

• Light jumps and landings on the sand

• Skips (different patterns)

5 • Aerobic fitness test • Sprinting and fast changes of direction

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2012;28:73-80. http://dx.doi.org/10.1097/ implications for clinical practice. Physiotherapy. http://dx.doi.org/10.2106/JBJS.D.02904

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• Introduce plyometrics in supine double-limb landing with gravity eliminated,

• Continue aquatic therapy for general endurance

• Minimal or no effusion (grade 0 or 1+)

• No or minimal effusion (grade 0 or 1+)

• Light jumps and landings on the sand

• Skips (different patterns)

5 • Aerobic fitness test • Sprinting and fast changes of direction