 
 
Rehabilitation Protocol for Microfracture of Femoral Condyle 
and Patella/Trochlear Groove 
 
This protocol is intended to guide clinicians and patients through the post-operative course for microfracture of the 
femoral condyle or patella/trochlear groove. Microfracture technique is a reparative technique used to treat articular 
cartilage defects. It is indicated for full-thickness articular cartilage loss in a weightbearing area between the femur and 
tibia or between the patella and trochlear groove. Controlled perforation of the subchondral bone is performed to 
stimulate marrow and stem cells to create a fibrocartilage callus that covers the lesion. 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. If you have questions, contact the referring 
physician.   
 
Considerations for the Post-operative Microfracture of femoral condyle and Patella/Trochlear groove protocol 
Many different factors influence the post-operative rehabilitation outcomes of the microfracture technique including: 
lesion size and location, cartilage quality and presence of concomitant injuries/procedures. Whether the procedure is 
performed on the femoral condyle (FC) versus the patella/trochlear groove (PTG) effects the protocol, see below for 
more detailed description. It is important to know location of the lesion and biomechanics of the knee for articular 
contact areas through the range of motion. Individual factors can also influence rehabilitation outcomes including: 
athlete’s age, BMI, sport, and competitive level. It is recommended that clinicians collaborate closely with the referring 
physician regarding these factors.  
If the patient develops a fever, intense calf pain, uncontrolled pain, uncontrolled swelling, or any other 
symptoms that are of concern call the physician immediately.  
 
PHASE I: PROTECTION & JOINT ACTIVATION (0-8 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Protect the surgical repair from shear and load forces 
• Restore full passive knee extension 
• Gradually restore knee flexion  
• Decrease pain and effusion 
• Restore quad control  
Weight Bearing &  
Brace  
FC Lesions: no brace  
• TTWB (20-30% BW) 0 to 6-8 weeks 
dependent on size and location of lesion 
 
PTG Lesions: 
• Week s 0-2: PWB (50%) – brace locked in 
extension.  
• Week 3: Progress to WBAT - brace locked in 
extension till week 6  
• Weeks 6-8: progressively open brace to 
maximum of 40° in weightbearing 
CPM 
FC Lesion: 
• Use 6-8 hours/day, in 2-hour blocks. 
• Start with knee at full extension to 30-40° 
degrees knee flexion. 
• Increase by 5-10°/day as tolerated  
• If unable to use a CPM perform 500 reps, 
3x/day of PROM knee flexion and extension. 
• Monitor for joint effusion and pain  
 
PTG Lesion: 
• Day 1: Use 10 hours (0-30°) 
• Day 2+: 6-8 hours/day, in 2-hour blocks 
• Progress to 60-90° by end of week 2.  
• Increase by 5-10°/ day  
• If unable to use a CPM perform 500 reps, 
3x/day of PROM knee flexion and extension. 
• Monitor for joint effusion and pain  
• May progress more slowly than FC lesions  
ROM Goals 
FC Lesions (PTG lesions will progress more slowly based on location of lesion): 
• Week 1: 0-90° 
• Week 2: 0-105° 
 
 
• Week 3: 0-115° 
• Week 4: 0-125° 
Intervention 
Pain and swelling management: 
• Cryotherapy 
• Elevation 
• Compression 
 
Manual Therapy: 
• Patella mobilizations – gentle with PTG lesions  
• Soft tissue mobilization 
 
Range of motion: 
• Heel prop for knee extension  
- May use overpressure of 6-12 lbs for low-load, long duration stretch – Only if having 
trouble attaining full extension.  
• Passive seated and supine heel slides: No forced flexion past 90° for 1st 2 weeks for PTG 
lesions 
• Ankle pumps  
• Gastrocnemius stretching 
• Hamstring stretching  
• Bike: Start at week 3,  
- No resistance  
- Pain-free  
 
Strengthening: No active NWB knee extension for PTG lesions  
• Weeks 0-4 
- Quad set  
- Multi-angle Isometrics  
- Glut and hamstring isometrics 
- NMES or biofeedback with quadriceps isometrics  
- 4-way SLR 
- Standing 4-way SLR 
- Long sitting PF with band in knee extension 
- Standing hamstring curl 
- Open chain knee EXT (90°-40°): FC Lesions only  
- SAQ: FC lesions only  
- Weight shifting: Start week 2, PTG lesions only 
- Standing heel and toe raises: Start week 4, PTG lesions only 
• Weeks 4-6:  
- Partial weight bearing leg press: 0-60° 
▪ 
PTG lesions and small FC lesions (< 2cm2) 
• Weeks 6-8: 
- PTG and small FC lesions: Progress partial weight bearing leg press: 0-90° 
- FC Lesions: Progress open chain knee Ext (90°-40°) 1 lb/week  
- Heel and toe raises: FC lesions  
- Small FC lesions (< 2cm2): Front lunges, lateral step up, front step ups, wall squats(0-
45°) – With assistive device, UE assist, or body weight support 
- PTG Lesions: Loaded flexion from 0-30° in brace 
▪ 
Mini squat, 4-inch step up 
 
Aquatic Therapy: Once incision is healed (2-3 weeks post-op) 
• Deep water to maintain weight bearing restrictions  
• Gait Training, kickboard  
• No flutter kicks for PTG lesions  
 
Patient Education: 
 
 
• Weight bearing restrictions  
• Use of CPM  
• Minimization of joint effusion 
Criteria to 
Progress 
• Full passive knee extension  
• Minimum of 125° knee flexion 
• < 3/10 knee pain  
• Minimal to no joint effusion 
• Elimination of quad lag with SLR  
 
PHASE II: PROGRESSIVE LOADING (8-12 WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Gradually increase mechanical stress applied to repaired tissue 
• Correct altered joint mechanics and neuromuscular control 
• Full knee ROM equal to uninvolved side 
• Gradual increase in quadriceps strength and endurance  
• Gradual return to functional activities  
• Maintain minimal to no joint effusion or pain 
Weight-
Bearing/Brace 
FC Lesions: 
• Progress to full weightbearing  
PTG Lesions 
• Full weightbearing 
• Discontinue use of brace  
CPM 
• Discontinue use of CPM – unless directed otherwise by surgeon 
Contraindications 
• No stair-master 
• No impact exercises  
• Avoid Pivoting 
• Avoid varus/valgus stress 
• No open chain knee extension with PTG lesions  
Additional 
Intervention 
*Continue with 
Phase I 
interventions 
Pain and swelling management: 
• Modalities as needed  
 
Manual Therapy: 
• Patella mobilizations as needed 
• Soft tissue mobilization as needed 
 
Aquatic Therapy: 
• Gait/running training  
• Strengthening  
 
Therapeutic Exercise: 
• Large FC Lesions (>2cm2) 
- Front lunge, front step ups, lateral step ups, wall sits and partial squats (0-45°) 
- Initiate partial weight bearing leg press(0-60°) 
• Bridges, bridge with legs on ball, single leg bridge 
• Mini Squat: 0-45°  
• Romanian dead lifts  
• 4-way SLR: Progress resistance  
• Standing Hamstring curls  
- Limit ROM with PTG lesions based on location for articulation 
• Step up progression: 2inches to 8 inches  
• TKE 
• Single leg knee bends 
- PTG 0°-30° 
- FC lesions: 0°-45° 
• Progress closed chain LE exercise within a ROM that doesn’t affect repairing cartilage.  
• Core strengthening: Planks, side planks 
 
Cardiovascular conditioning: 
 
 
• Elliptical 
• Initiate a walking program @ 10-12 weeks 
- Start with -5-10 minutes; add 5min/wk 
 
Balance and proprioception:  
• Double leg:  
- Stable and unstable  
- Eyes open and closed  
- Squats on wobble board 
• Single leg: begin when cleared to progress to full weight bearing  
- Stable and unstable  
- Eyes open and closed  
- External distractions/perturbations  
Criteria to 
Progress 
• Full and painless knee ROM  
• < 3/10 pain with all activity  
• No or minimal effusion 
• Single leg balance > 30% of uninvolved side or greater than 15 seconds 
• 10 repeated single knee bends with good form and no reactive effusion or exacerbation of 
symptoms 
• Star excursion balance test: 20-30% of uninvolved side with good form and no reactive effusion 
or exacerbation of symptoms  
 
PHASE III: REMODELING (12-16WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Improve muscular strength and endurance  
• Increase functional activities.  
• Perform activities with minimal to no joint effusion or pain 
Weight Bearing 
• Full weight bearing  
Precautions 
• Post-activity soreness should resolve within 24 hours 
• Avoid post-activity swelling  
Additional 
Intervention 
*Continue with 
Phase II 
Interventions  
Cardiovascular conditioning: 
• Elliptical  
• Bike: 30 -45 min slowly increasing resistance as tolerated. 
• Stairmaster  
• Treadmill walking – increasing distance, speed, incline 
 
Strengthening: 
• Open chain knee extension:  
- PTG Lesions: Initiate open chain knee extension 90°-40°; or angle that avoids 
articulation with lesion. – No resistance 
- FC Lesions: Progress to 0°-90° 
• Unilateral step-up progression: 2-inch to 8-inch  
• Leg Press: 0°-90°  
• Squats: 0°-60°  
• Step downs: 2-inch to 8-inch progression Crucial to have adequate quad control with PTG 
lesions, if not then avoid until have adequate quad control.   
• Hip Strengthening: Band walks, side planks with clam, side planks with hip ABD 
• Progress core strengthening  
 
Balance and Proprioception: 
• Progress single leg balance: Bosu single leg balance, bosu squats, bosu single leg squats, dyna-
disk single leg balance/squats 
• Addition of ball toss, or UE coordination drills in DL/SL positions and stable/unstable surfaces  
 
 
 
Criteria to 
Progress 
• Full non-painful ROM 
• No reactive pain, inflammation or swelling with activities  
• Hamstring and quad strength > 80% of uninvolved side with HHD or isokinetic testing 
• Balance and/or stability > 75-80% of uninvolved leg  
• 20 repeated single leg step downs with good form and no reactive effusion or symptoms  
• 20 repeated SL partial squats to 60° with good form and no reactive effusion or symptoms  
 
PHASE IV: MATURATION PHASE (16+ WEEKS AFTER SURGERY) 
Rehabilitation 
Goals 
• Gradual return to full unrestricted activities 
• Single leg hop test within 75-80% of uninvolved leg  
• Begin progression to jogging 
• All activities are performed with good form and without reactive, pain, inflammation, and 
effusion 
Additional 
Intervention 
*Continue with 
Phase III 
interventions 
Begin impact loading programs depending on location and size of lesion and surgeon clearance.  
• Staged running program: 4-5 months for small lesions, 6 months for large lesions  
- Perform on a forgiving surface 
- Start with 1 min/running, 4-min/walk 
- Running time is increased 1 min/week and walking time decreased 1-min/week, until 
able to complete 20 minutes of continuous running after week 5  
• Initiate agility drills: single plane completed at 25% maximum speed;  
- Increase 25% increase speed/week 
- Progress to multi-direction drills  
Strengthening: 
• Emphasize entire lower extremity strengthening 
• Progress resistance as tolerated  
• NWB Knee Extension: PTG lesions – Starting week 20  
- Add 1lb/2weeks if no pain or crepitus 
- Perform from 90-40 deg or angle that avoids lesion articulation  
Plyometrics: 
• 16-18 weeks: PWB plyometrics, aquatic plyometrics, Gravity eliminated double leg hopping 
- Progress to SL aquatic plyometrics, SL gravity eliminated hopping, SL PWB 
hopping/plyometrics 
• 18-20 weeks: DL box drop to forgiving surface, DL hopping forgiving surface 
- Progress to SL hopping, and to firmer surfaces  
- Box jumps, Double leg hopping in place, Single leg hopping in place, quick 
hops(front/back/side) 
• Slowly progress amount of body weight with double leg 1st then progress through single leg.  
• Start with compliant surfaces like foam 
 
Return to sport 
timelines 
• Low-impact sports/activities: Swimming, skating, rollerblading, and cycling 
- 2 months – Small FC lesions and PTG lesions 
- 3 months – Large FC lesions  
• Higher-impact sports/activities: jogging, running, and aerobics  
- 4-5 months: Small FC lesions and PTG lesions  
- 6 months: Large lesions  
• High-impact activities (requires jumping, pivoting, cutting): football, basketball, tennis, soccer, 
baseball 
- 6-8 months: Small FC lesions and PTG lesions  
- 9-12 months: Large FC lesions  
 
 
Criteria to Return 
to Sport 
• Physician Clearance  
• LE strength within 90% of uninvolved leg with HHD or isokinetic testing  
• Score > 90% of Knee Outcome Survey activities of daily living scale (KOS-ADLS) 
• Symmetry with functional testing:  
- Triple hop 
- Crossover hopping 
- Long jump 
• No reactive pain, inflammation, effusion, or instability with sport-specific activity 
Revised 12/2021 
 
Contact 
Please email MGHSportsPhysicalTherapy@partners.org with questions specific to this protocol 
References: 
 
1. 
Gill TJ, Asnis PD, Berkson EM. The treatment of articular cartilage defects using the microfracture technique. Journal of Orthopedic and Sports 
Physical Therapy. 2006; 36(10): 728-738.  
2. 
Juneau C, Paine R, Chicas E, et al. Current concepts in treatment of patellofemoral osteochondritis dissecans. The International Journal of Sports 
Physical Therapy. 2016;11(6):903-925.  
3. 
Logerstedt DS, Scalzitti DA, Bennell KL, et al. Knee pain and mobility impairments: meniscal and articular cartilage lesions revisions 2018. Journal of 
orthopedics and Sports Physical Therapy. 2018; 48(2): A1-A50.  
4. 
MGH Sports medicine. Arthroscopic microfracture rehabilitation protocol. https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/sports-
medicine/physical-therapy/rehabilitation-protocol-for-microfracture-knee.pdf. Accessed on August 1, 2021.  
5. 
Mithoefer K, Hambly K, Logerstedt D, et al. Current concepts for rehabilitation and return to sport after knee articular cartilage repair in the athlete. 
Journal of Orthopedics and Sports Physical Therapy. 2012;42(3): 254-273. 
6. 
Ohio State University. Knee microfracture clinical practice guidelines. https://medicine.osu.edu/-/media/files/medicine/departments/sports-
medicine/medical-professionals/knee-ankle-and-foot/microfracturef2020.pdf?la=en&hash=DAE824282B7B4BED327698E054EB7B01142F43E7. 
Accessed on August, 16, 2021.  
7. 
Reinold M, Wilk K, Macrina L, et al. Current concepts in rehabilitation following articular cartilage repair procedures in the knee. Journal of 
Orthopedics and Sports Physical Therapy. 2006;36(10):774-794. 
8. 
Schmitt LC, Quatman CE, Paterno MV, et al. Functional outcomes after surgical management of articular cartilage lesions in the knee: a systematic 
literature review to guide postoperative rehabilitation. Journal of Orthopedics and Sports Physical therapy. 2014; 44(8): 565-578.  
9. 
Steadman JR, Rodkey WG, Rodrigo JJ. Microfracture: surgical technique and rehabilitation to treat chondral defects. Clinical Orthopaedics and 
Related Research. 2001; 391S: 362-369.  
10. Tetteh ES, Bajaj S, Ghodadra NS, Cole BJ. Basic science and surgical treatment options for articular cartilage injuries of the knee. Journal of 
Orthopedics and Sports Physical Therapy. 2012 42(3): 243-253.  
11. University of Wisconsin sports medicine. Rehabilitation guidelines following Microfracture procedure to the knee. 
https://www.uwhealth.org/files/uwhealth/docs/pdf/SM-158902_Microfracture_Knee.pdf. Accessed on August 15, 2021.  
12. Wilk KE, Macrina LC, Reinold MM. Rehabilitation following microfracture of the knee. Cartilage. 2010;1(2):96-107. 
13. Yen YM, Cascio B, O’Brien L, et al. Treatment of osteoarthritis of the knee with microfracture and rehabilitation. Medicine and Science in Sports and 
Exercise. 2008; 40(2):200-205. 
 
 
 
