High Tibial Osteotomy (HTO)

Rehabilitation Protocol

High Tibial Osteotomy (HTO) Rehabilitation Protocol

Rehabilitation Philosophy

This protocol is criteria-based and biologically informed, designed to optimise recovery following medial opening-wedge high tibial osteotomy while protecting bone healing and fixation.

Timelines are guides only, progression is dictated by radiographic union, symptom response, movement quality, and functional strength, not time alone.

Key Biological Considerations

  • Bone healing is the primary rate-limiting step

  • HTO generally tolerates earlier loading than DFO, but remains load-sensitive in the early phase

  • Early joint motion and quadriceps activation are encouraged

  • Progressive loading must follow fixation stability and early radiographic union

  • Long-term outcomes are driven by strength, neuromuscular control, and alignment management

  • Walking supports mobility but does not replace strengthening

Clinical Governance & Escalation

Persistent medial tibial pain, swelling, gait regression, or failure to progress warrants immediate load modification and review with Dr Lynskey.

View all Rehabilitation Protocols

Preoperative Phase (Prehabilitation)

Goals

  • Full knee extension

  • Optimised quadriceps activation

  • Maintenance of hip and core strength

  • Preparation for protected weight bearing post-operatively

Clinical Notes

  • At least one pre-operative physiotherapy session is recommended

  • Education regarding:

    • Crutch use

    • Early weight-bearing restrictions

    • Expected rehabilitation timeline and milestones

Phase 1 – Bone Protection (0–6 Weeks)

Goals

  • Protect osteotomy and fixation

  • Maintain full knee extension

  • Control pain and swelling

  • Preserve quadriceps activation

Weight Bearing

  • Typically non-weight bearing → partial weight bearing, as directed by the surgeon

Rehabilitation Focus

  • Active knee ROM (extension prioritised)

  • Quadriceps sets and straight leg raises

  • NMES if quadriceps inhibition present

  • Heel props and extension stretches

  • Hip, core, and contralateral limb strengthening

  • Upper-body conditioning

  • Cryotherapy and elevation as required

Avoid

  • Impact loading

  • Torsional stress

  • Aggressive strengthening across the knee

Phase 2 – Progressive Loading (6–12 Weeks)

(Following evidence of early radiographic healing)

Goals

  • Gradual reintroduction of load

  • Restore functional knee ROM

  • Normalise gait mechanics

Rehabilitation Focus

  • Progress to WBAT once cleared

  • Closed kinetic chain strengthening:

    • Sit-to-stand

    • Mini-squats

    • Low-height step-ups

  • Stationary cycling

  • Balance and proprioceptive training

Monitor Closely

  • Localised medial tibial pain

  • Swelling response

  • Gait quality and symmetry

Phase 3 – Strength & Capacity (3–6 Months)

Goals

  • Restore quadriceps and hip strength

  • Improve endurance and neuromuscular control

  • Increase functional tolerance

Rehabilitation Focus

  • Progressive resistance training

  • Gradual increase in squat depth as tolerated

  • Step-down control

  • Dynamic balance and alignment control drills

Phase 4 – Advanced Function (6–9+ Months)

Goals

  • Restore higher-level functional capacity

  • Prepare selected patients for recreational sport

Rehabilitation Focus

  • Higher-load functional strengthening

  • Directional and frontal-plane control drills

  • Low-level plyometrics only once radiographic union is confirmed and control is excellent

Return To Activities (Criteria-Based)

Required Criteria

  • Radiographic union

  • No focal medial tibial tenderness

  • Minimal or no effusion

  • Independent, non-antalgic gait

  • Adequate strength for stairs and sit-to-stand tasks

Encouraged

  • Walking

  • Cycling

  • Swimming

  • Hiking

  • Gym-based strengthening

Cautioned / Often Delayed

  • Running

  • Impact and pivoting sports
    (Often delayed long-term or avoided depending on indication, cartilage status, and alignment goals).

Surgeon Notes (VBJS)

  • Bone healing is the primary rate-limiting step following HTO

  • Temporary muscular discomfort is expected; focal bony pain is not

  • Load progression must follow imaging confirmation of union

  • Modify rehabilitation for:

    • Concomitant cartilage or meniscal procedures

    • Smoking or metabolic risk factors

  • Concerns regarding delayed union, pain regression, or functional decline should prompt early review with Dr Lynskey

Key Clinical Message

Early controlled movement preserves joint mobility, but progressive strengthening and impact exposure must follow confirmed bone healing to ensure durable outcomes after high tibial osteotomy.

Have a question or want to book an appointment?

Request a Consultation