 
 
Rehabilitation Protocol for High Tibial Osteotomy 
Reconstruction  
 
This protocol is intended to guide clinicians through the post-operative course for High Tibial Osteotomy reconstruction. 
This protocol is time based (dependent on tissue healing) as well as criterion based. Specific intervention should be 
based on the needs of the individual and should consider exam findings and clinical decision making. The timeframes for 
expected outcomes contained within this guideline may vary based on surgeon’s preference, additional procedures 
performed, and/or complications. If a clinician requires assistance in the progression of a post-operative patient, they 
should consult with the referring surgeon. 
 
The interventions included within this protocol are not intended to be an inclusive list. Therapeutic interventions should 
be included and modified based on the progress of the patient and under the discretion of the clinician. 
 
Considerations for the Post-operative 
Many different factors influence the post-operative high tibial osteotomy rehabilitation outcomes, including the 
presence of additional surgical procedures. It is recommended that clinicians collaborate closely with the referring 
physician regarding protocol. 
 
If the patient develops a fever, unresolving numbness/tingling, excessive drainage from the incision, uncontrolled pain 
or any other symptoms you have concerns about, the referring physician should be contacted. 
 
PHASE I: IMMEDIATE POST-OP (0-6 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Protect the anatomic repair 
• Monitor wound healing 
• Minimize knee effusion 
• Increase tibial-femoral and patella-femoral mobility 
• Restore quadriceps control 
• Gently increase ROM per guidelines – emphasis on extension 
Precautions  
• No active knee extension 
• No resisted closed chain or open chain until 6 weeks post-op 
Weight Bearing 
• Week 0-4: NWB/ TDWB with brace locked in extension 
• Week 4-6: TDWB with brace locked in extension progressing to PWB  
- Progress to brace unlocked in PWB if have full extension and good quadriceps control  
Brace 
• Hinged knee brace locked in 0 degrees extension for all mobility and gait until at least 4 weeks 
post-op, full knee extension achieved and good quad control.  
• Brace may be unlocked when sitting or in bed 
Interventions 
Range of Motion 
• Knee AAROM/PROM – Passive extension only  
- Week 0-4: 0-90 degrees  
- Week 4-6: 0-120 degrees  
- Prone hangs, supine knee extension with heel prop, heel slides with PROM for knee 
extension, knee flexion in sitting with P/AAROM for knee extension 
 
Strengthening 
• Quad sets  
• Gluteal sets  
• Ankle pumps  
• Side-lying hip ABD – with brace until elimination of quad lag 
 
 
• Prone Hip Extension – with brace until elimination of quad lag 
• SLR – per MD recommendation, depending on surgical approach, may be inappropriate 
- Perform with brace locked in extension, D/C brace when performed without a lag 
• Side-lying Hip Adduction – with brace until elimination of quad lag 
• Clam shell 
• Hamstring stretch  
• ITB stretch  
• Gastroc-soleus stretch 
• Bike – No resistance  
 
Aquatic therapy – if available  
• Deep water (chest/shoulder height) – walking and ROM exercises  
- Core stability and UE exercises  
 
Manual Therapy 
• Patella mobilizations – immediately post-op 
• Gentle STM – 2-3 weeks post-op 
 
Modalities 
• NMES for quadriceps re-education/biofeedback. 
• Cryotherapy for swelling and pain management.  
• Taping – pain and swelling management.  
Criteria to 
Progress 
• Knee PROM: 0-120 degrees  
• Adequate pain control 
• Minimal swelling 
• Able to perform SLR without quadriceps lag 
 
PHASE II: PROTECTION PHASE (7-12 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Increase mobility 
• Restore quadriceps control 
• Restoration of full ROM by week 8-12 
• Progress weight bearing 
• Normalize gait pattern without assistive device – goal of 2 miles at 15min/mile pace on a 
treadmill 
• Gradual progression of therapeutic exercises for strengthening, stretching and balance 
Precautions 
• No weight bearing stretching into knee flexion until week 8 
• Avoid descending stairs reciprocally until adequate quadriceps control as demonstrated by SLR 
• Avoid exercises/activities with excessive patella-femoral compression forces (deep squats, 
resisted open chain terminal knee extension) 
• Avoid medial collapse due strengthening and functional activities  
• No running, jumping or plyometrics until 4-6 months post-surgery 
• Do not overload the surgical site 
• Modify activity level if increased pain, edema or catching occurs 
Weight Bearing 
• WBAT per MD, based on X-ray 
Brace 
• Brace unlocked for ambulation if there is good quad control, crutches as needed 
• Hinge brace until week 8 then replace with patellofemoral brace with lateral buttress 
Additional 
Interventions 
*Continue with 
Phase I 
interventions as 
needed 
Modalities 
• NMES for quadriceps re-education – as needed  
• Cryotherapy for edema and pain management  
 
Manual Therapy 
• Patella mobilizations 
• Soft tissue mobilization  
 
 
 
 
Range of Motion 
• Progress PROM/AAROM/AROM of knee as tolerated 
Stretching 
• Hamstring  
• Gastroc -Soleus  
• Prone Quadriceps with strap 
 
Strengthening  
• TKE – 0-40 degrees  
• Leg press 
• Partial range wall squats 
- 0-45 degrees 
• Forward step ups, Lateral step ups 
• Forward, Lateral, Retro step downs 
• Bridge with physioball 
• Romanian Deadlifts – Week 7 
- Standing upright to weight just below knees. 
• Band walks – Week 8 
• Stool walks – Week 8  
• BOSU Partial squat – Week 9 
- 0-60 degrees  
• Prone Hamstring curl – 10 weeks  
- Begin with ankle weights and progress to weight machine 
 
Cardiovascular Exercise 
• Stationary Bike – light resistance 
• Treadmill – forward and backwards 
• Elliptical – week 9-10  
 
Aquatic Therapy 
• Flutter kicks 
• Straight leg scissor kicks 
• Running in waist deep water  
 
Balance 
• Progress from double to single leg balance 
• Progress from static to dynamic:  
- BAPS 
- Ball toss  
- Body blade  
- Fitter  
- Slide board 
Criteria to 
Progress 
• Full range of motion 
• Elimination of swelling 
• Restoration of normal gait  
• Quad strength > 70% of uninvolved leg  
 
PHASE III: ADVANCED STRENGTHENING (13-16 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Normal tibial-femoral and patella-femoral mobility  
• Restoration of quadriceps control  
• Progress muscle strength, endurance, and balance activities  
Precautions 
• No running, jumping or plyometrics till 4-6 months post-op 
• May continue with patellofemoral hinged brace until 12 months post-op for lighter level 
activities – Based on MD recommendation.  
 
 
Additional 
Interventions 
*Continue with 
Phase I-II 
Interventions  
Strengthening 
• Total leg strengthening  
• Single leg strengthening  
• Hamstring isotonic exercises through full ROM 
• Quadriceps isotonic exercises  
 
Proprioception 
• Single leg balance  
- Stable and unstable surfaces 
• Single leg balance with leg swings  
• Single leg balance with ball toss  
• Single leg balance with UE perturbations 
 
Cardiovascular Exercise 
• Bike, elliptical  
• Treadmill walking  
Criteria to 
Progress 
• Full, symmetrical pain-free ROM 
• Strength: 80%+ of uninvolved leg 
• Satisfactory clinical exam 
• MD approval to progress to next phase 
 
PHASE IV: EARLY RETURN TO SPORT PHASE (16+ WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Progress to higher level activities – based on functional demands and MD approval  
• Return to vocational, recreational and/or sport activities.  
• Run 2 miles at easy pace – if appropriate 
Additional 
Interventions 
*Continue with 
Phase III 
interventions 
Running: begin at 4 months 
• Start with light gentle slow-paced running 
• Treadmill running  
- Must demonstrate good running form for 5 minutes with equal audibly rhythmic foot 
strike.  
• Aquatic running  
• Backwards and forward running  
• Initiate Return to running protocol 
 
Plyometrics: 4.5 –to 5 months 
• Start with double leg drills  
• Progress slowly to single leg drills 
• Ensure good form and proper hip and knee alignment 
 
Agility Drills: 4.5 to 5 months 
• Sub-max foot placement drills  
• Ladder drills  
• Line hops  
Criteria to 
Progress 
Return to sport/play: 7 to 9 months 
• Quad and hamstring strength 90% of uninvolved 
• Full symmetrical knee range of motion 
• No knee joint effusion 
• Single leg hop test: Limb symmetry of 90% 
• Triple hop test: limb symmetry of 90% 
• Cross-over hop test: limb symmetry of 90% 
• Refer to lower extremity functional assessment   
Revised 10/2021 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
 
 
 
References 
1. 
Avramidis K, Strike PW, et al. Effectiveness of electrical stimulation of the vastus medialis muscle in rehabilitation of patients after total knee 
arthroplasty. Arch Phys Med Rehabilitation. 2003; 84: 1850-1853.  
2. 
Bhave A Mont M Tennis S, et al. Functional problems and treatment solutions after total hip and knee arthroplasty. Journal of Bone and Joint Surgery. 
2005; 87(2): 9-21. 
3. 
Buuk DA, Fulkerson JP. Anteromedialization of the tibial tubercle: A 4-12 year follow up. Operative techniques in sports medicine. 2000; 8(2): 131-
137 
4. 
Choi MY, Kong DH, Kim JS, et al. Rehabilitation program after medial open wedge high tibial osteotomy. Arthroscopy and orthopedic sports medicine. 
2019; 6(1): 1-8.  
5. 
Ekhtiari S, Bkin, Haldane CF, et al. Return to work and sport following high tibial osteotomy: A systematic review. The journal of bone & joint 
surgery. 2016; 98A(18): 1568-1577.  
6. 
Farr J. Techniques in knee surgery. Tibial tubercle osteotomy. Lippincott Williams & Wilkins Inc. 2(1): 28-42, 2003.  
7. 
Gomoll AH, Minas T, Farr J, Cole BJ. Treatment of chondral defects in the patellofemoral joint. The Journal of knee surgery. 2006; 19(4): 285-295. 
8. 
Hischman MT, Hoffman M, Krause R, Jenabzadeh RA, et al. Anterolateral approach with tibial tubercle osteotomy versus standard medial approach 
for primary total knee arthroplasty; Does it matter? BMC musculoskeletal disorders. 2010; 11: 167, p3.  
9. 
Hocking RA, Bourne RB. Techniques in knee surgery. Tibial tubercle osteotomy in revision total knee replacement. Lippincott Williams & Wilkins 
Inc. 2007; 6(2): 88-92.  
10. Hoorntje A, Kuijer PFM, van Ginneken BT, et al. Prognostic factors for return to sport after high tibial osteotomy. The American journal of sports 
medicine. 2019; 47(8): 1854-1862. 
11. Koeter S, Wymenga AB. Tibial Tubercle Osteotomy. Knee Surg Sports Traumatology, Arthroscopy. 2008; 16:627. 
12. Koeter S, Diks MJF, Anderson PG, Wymenga AB: A modified Tibial tubercle osteotomy for patellar maltracking. The Journal of bone surgery. 2007; 
89-B: 180-185.  
13. Krych AJ, O’Malley MP, Johnson NR et al. Functional testing and return to sport following stabilization surgery for recurrent lateral patellar 
instability in competitive athletes. Knee Surg Sports Traumatology Arthroscopy 2018; 26:711-718. 
14. Liu JN, Wu HH, Garcia GH et al. Return to Sports After Tibial Tubercle Osteotomy for Patellofemoral Pain and Osteoarthritis. Arthroscopy: The 
Journal of Arthroscopic and Related Surgery 2018; 34(4):1022-1029. 
15. McKinnis LN. Radiologic evaluation of the knee. In: Fundamentals of musculoskeletal imaging. 2nd ed. Philadelphia: F.A. Davis; 2005: 329-364.  
16. Salari N, Horsmon G, Cosgarea A. Rehabilitation after anteromedialization of the tibial tuberosity. Clinical sports medicine. 2010; 29: 303-311.  
17. Saltzman BM, Rao A, Erickson BJ et al. A Systematic Review of 21 Tibial Tubercle Osteotomy Studies and More than 1000 Knees: Indications, Clinical 
Outcomes, Complications, and Reoperations. The American Journal of Orthopedics 2017;E396-E407. 
18. Sherman SL, Erickson BJ, Cvetanovich GL et al. Tibial Tuberosity Osteotomy. The Journal of Sports Medicine 2014; 42(8):2006-2017. 
19. Wolcott M, Traub S, Eddrid C. High tibial Osteotomies in the young active patient. International Orthopaedics. 2010; 34: 161-166.  
20. The Cartilage repair center. Available at http://www.cartilagerepaircenter.org accessed on July 1, 2021.  
21. Gundersen Health System. Distal Patellar Realignment Rehabilitation Program Fulkerson Osteotomy Tibial Tubercle Osteotomy (TTO). Available at: 
https://www.gundersenhealth.org/app/files/public/1465/Sports-Medicine-Protocol-Distal-Patellar-Realignment.pdf. Accessed June 30, 2021 
22. University Orthopedics. Tibial Tubercle Osteotomy. Available at: https://universityorthopedics.com/assets/layout/TIBIAL-TUBERCLE-
OSTEOTOMY.pdf. Accessed June 30, 2021.  
23. OrthoIndy. Tibial Tuberosity Osteotomy Rehabilitation Protocol. Available at: 
https://www.orthoindy.com/UserFiles/File/Tibial%20Tuberosity%20Osteotomy%20(TTO)%20Rehabilitation%20Protocol.pdf. Accessed June 30, 
2021.  
 
 
 
