Evidence / Sources / E4
Edwards PK, Ackland T, Ebert JR. Clinical rehabilitation guidelines for MACI on the tibiofemoral joint. JOSPT 2014;44(2):102-19
What it can tell you
The field's canonical tibiofemoral protocol, in full: seven phases from inpatient PRICE and CPM (0–30°, within 24 hours) through a graduated weight-bearing ladder (20% → 30% at weeks 2–3 → 40–60% at weeks 4–6 → full by week 8), full active flexion generally permitted by week 6, recumbent-then-upright cycling, neuromuscular training from the first unaided steps, and their institution's recommendation to delay repetitive impact to 9–12 months after seeing bone-marrow edema in earlier returners.
What it cannot
Whether any of it is optimal — the paper self-designates 'Therapy, level 5': a clinical commentary presenting one institution's protocol. Its weight-bearing spine encodes that group's own randomized work (E1–E3); everything else is convention with a rationale. The impact-delay advice rests on an anecdote the authors themselves label as such.
Everything on this site that leans on E4 — 93 claims
Stage II · Protection [patellofemoral]“Quadriceps activation sufficient for a straight-leg raise without lag.”Stage III · Loading [patellofemoral]“For patellofemoral grafts the consensus progressed unloaded motion toward full active range at six to ten weeks, averaging seven to nine across its patient profiles, while loading …”Stage III · Loading [patellofemoral]“Level walking 30 minutes without limp or next-day effusion.”Program · Stage II (patellofemoral)“Quadriceps sets — Push the back of the knee down, tighten the thigh, hold. Isometric work started around week one in half of published protocols.”Program · Stage II (patellofemoral)“Straight-leg raise, in the brace — The patellofemoral joint is barely loaded with the knee straight; a locked brace keeps it that way while the leg works.”Program · Stage II (patellofemoral) · Gates“Straight-leg raise with no extension lag”Program · Stage II (tibiofemoral)“Weight-bearing, the bottom of the ladder — An electronic bathroom scale is the published teaching method: load the leg on the scale until the number matches, and remember the feel.…”Program · Stage II (tibiofemoral)“Hydrotherapy, deep water first — A convention of the canonical protocol; no trial has tested hydrotherapy in cartilage repair.”Program · Stage II (tibiofemoral)“Passive motion, from the first day — Gained, never forced. CPM appears in about three-quarters of published protocols; no trial has isolated its dose.”Program · Stage II (tibiofemoral)“Active flexion, early and unloaded — The near-opposite of the patellofemoral rule: flexion was never the protected variable here; weight was.”Program · Stage II (tibiofemoral)“Isometrics — quadriceps, hamstrings, gluteals — Push the back of the knee down, tighten the thigh, hold. Isometric work started around week one in half of published protocols.”Program · Stage II (tibiofemoral)“Straight-leg raises, all planes — The canonical protocol kept a brace on 24 hours a day for the first 3–4 weeks; the brace weeks in your protocol are its authors' convention.”Program · Stage II (tibiofemoral) · Gates“Active flexion at 90° by the early weeks and approaching full by week six, gained rather than forced”Program · Stage II (tibiofemoral) · Gates“Straight-leg raise with no extension lag”Program · Stage III (patellofemoral)“Leg press, shallow arc only — Add load only when the previous week caused no swelling by the next morning. Both legs, then single.”Program · Stage III (patellofemoral)“Straight-leg raise, no lag — If the heel lifts late or the knee bends first, drop back to quad sets. Lag is the signal, not pain.”Program · Stage III (patellofemoral) · Gates“Straight-leg raise with no extension lag”Program · Stage III (patellofemoral) · Gates“Level walking 30 min without limp or next-day effusion”Program · Stage III (patellofemoral) · Gates“Single-leg stance held 30 seconds”Program · Stage III (tibiofemoral)“Weight-bearing, up the ladder — A bathroom scale is the published method for hitting a prescribed percentage: load the leg on the scale until the number matches, and remember the f…”Program · Stage III (tibiofemoral)“Gait, made boring again — A limp is information — the dose was too high, not a thing to push through. Distance before speed.”Program · Stage III (tibiofemoral)“Active flexion to full range — The near-opposite of the patellofemoral rule. Flexion here was never the protected variable; weight was.”Program · Stage III (tibiofemoral)“Cycling, recumbent then upright — Recumbent before upright because it asks less flexion and less compression of the same knee.”Program · Stage III (tibiofemoral)“Closed-chain quadriceps work begins — Weight-bearing exercise produces lower tibiofemoral shear than open-chain — the biomechanical reason protocols start here.”Program · Stage III (tibiofemoral)“Balance and neuromuscular work, from the first unaided steps — No study has measured proprioception in cartilage-repair patients specifically — the canonical protocol reasons from …”Program · Stage III (tibiofemoral) · Gates“Full active range of motion, without a swelling response”Program · Stage III (tibiofemoral) · Gates“A pain-free, unaided six-minute walk with a normalized pattern”Program · Stage IV (tibiofemoral)“Leg press, squats, lunges — the strength block — The patellofemoral program guards flexion depth in this window; this side guards load. Same stage, different dial.”Program · Stage IV (tibiofemoral)“Outdoor cycling, rowing, ellipticals — The canonical protocol moves cardio outdoors here. Its week numbers are convention, not tested doses.”Program · Stage IV (tibiofemoral)“Work and daily load, by demand tier — The canonical protocol places return to work in this window; the demand tiers are the consensus panel's.”Program · Stage V (tibiofemoral)“Heavy strength work, continued — Impact weeks are not a reason to stop lifting. The strength base is what the new load lands on.”Program · Stage V (tibiofemoral)“Prolonged walking, uneven ground, low-impact recreation — Uneven ground is where the balance work of Stage III pays out. It is trained here, deliberately, not discovered by acciden…”Program · Stage V (tibiofemoral)“Running, by evaluation then intervals — The 9–12-month caution rests on an anecdote the authors label as such: patients running at 6–9 months often reported graft-site pain with mo…”Program · Stage V (tibiofemoral)“Sport, tier by tier — Pooled return to sport across cartilage procedures runs about 80% — but in pivoting sports the range is 33–96% returned, and most studies never defined "retur…”Program · Stage VI (tibiofemoral)“Extensor strength work, indefinitely — Association, not causation — a Level IV series cannot say whether strong quads protect knees or good knees permit strong quads. It is still t…”Program · Stage VI (tibiofemoral) · Gates“Strength and impact work continuing past year one as part of the operation, not its aftermath”Exercise Library · Quadriceps set (isometric)“Isometric quadriceps work started around week one in roughly half of published MACI protocols, and from the first days in the canonical tibiofemoral protocol.”Exercise Library · Straight-leg raise, in the brace“Straight-leg raises in a brace locked in extension appear across published patellofemoral protocols and in the US expert consensus as early-stage extensor work.”Exercise Library · Straight-leg raises, all planes“The canonical tibiofemoral protocol introduces straight-leg raises in all planes from weeks 2–3, alongside a brace worn 24 hours a day for the first 3–4 weeks.”Exercise Library · Active flexion, early and unloaded“The canonical tibiofemoral protocol works active-assisted flexion within 30° in the first week, 90° by weeks 2–3, and beyond 125° by weeks 4–6, with full active flexion generally p…”Exercise Library · Hydrotherapy, deep water first“Hydrotherapy from wound healing, deep water first, is a convention of the canonical tibiofemoral protocol.”Exercise Library · Leg press, shallow arc“Closed-chain quadriceps work in a restricted shallow-flexion arc is the patellofemoral pattern across published MACI protocols and the canonical protocol literature.”Exercise Library · Closed-chain quadriceps work begins“Every protocol in the practice-pattern review that reported closed-chain work had started it by week seven — four of the twenty-five studies reviewed, and the only source that give…”Exercise Library · Straight-leg raise, no lag“The protocols this site cites prescribe straight-leg work as an exercise and state no standard a raise has to meet.”Exercise Library · Straight-leg raise, no lag · Evidence for this movement“That it belongs here — two accounts, one clinic”Exercise Library · Active flexion to full range“Full active flexion is generally permitted from week 6 in the canonical tibiofemoral protocol, with unweighted rowing-ergometer work as its published assist.”Exercise Library · Gait, made boring again“The US expert consensus ranked a normal gait pattern and crutch-free confidence above pain reduction as the milestone for this window.”Exercise Library · Cycling, recumbent then upright“Stationary cycling begins at 3–6 weeks in the US expert consensus. The canonical tibiofemoral protocol starts recumbent on a modified crank once 90° of active flexion allows a full…”Exercise Library · Balance and neuromuscular work“The canonical tibiofemoral protocol prescribes balance and neuromuscular training from the first unaided steps, reasoning from other knee procedures and stating that it does so.”Exercise Library · Leg press toward functional load“Terminal knee extension, leg press, and functional squats and lunges are the canonical tibiofemoral protocol's strength block for the three-to-six-month window.”Exercise Library · Low-impact cardiovascular work“The canonical tibiofemoral protocol introduces outdoor cycling, rowing and elliptical work from around twelve weeks, in the same window it stops relying on hydrotherapy.”Exercise Library · Returning to work“The expert consensus placed sedentary work at two to four weeks, unrestricted daily activities from around three months, and heavy labour at three to six months for less complex ca…”Exercise Library · Walking on uneven ground“The canonical tibiofemoral protocol places prolonged walking, uneven ground, and low-impact recreation in the six-to-nine-month window, ahead of repetitive impact.”Exercise Library · Running progression“The expert consensus placed running evaluation at six months for less complex cases and eight for more complex and clearance at seven to nine months for less complex cases and ten …”Benchmarks · flexion milestones“CPM 0–30°, from the first day — tibiofemoral, passive”Benchmarks · flexion milestones“Active-assisted within 30° — tibiofemoral, active assisted”Benchmarks · flexion milestones“Active flexion to 90° — tibiofemoral, active”Benchmarks · flexion milestones“Beyond 125° — tibiofemoral, active”What we don't know · № 06“A paper this site could not access, then obtained and read in full.”What we don't know · № 14“No study ever compared an earlier return — to running, work, or sport — against a later one.”Multifocal disease · lesions in both compartments — why this site has a combined mode“The two locations' rehabilitation programs protect opposite things: the tibiofemoral protocols restrict weight-bearing while allowing motion, and the patellofemoral consensus allow…”Week ruler · week 1 (tibiofemoral)“The joint is moved passively through a short arc within the first day, while the leg carries almost nothing — toe-touch only, taught against a bathroom scale.”Week ruler · week 2 (tibiofemoral)“The knee starts bending under its own muscle rather than a machine, and the ladder's second rung arrives — still a third of your body weight, still on crutches.”Week ruler · week 3 (tibiofemoral)“The canonical protocol keeps a brace on around the clock for the first three to four weeks. When it comes off is your surgeon's call, and the range across published protocols is mu…”Week ruler · week 4 (tibiofemoral)“Range runs well ahead of weight on this side: the knee is bending past 125° while the leg is still carrying under two-thirds of you.”Week ruler · week 4 (tibiofemoral)“The canonical ladder's middle rungs. The randomized arms did not share them — two spent a fortnight at 20% and then climbed to full, and the slowest used a 50% rung this ladder doe…”Week ruler · week 6 (tibiofemoral)“Bending stops being rationed on this side. Weight still is — which is the whole asymmetry of a graft that sits under the load path.”Week ruler · week 4 (tibiofemoral)“Eight of the twenty-five reviewed protocols trained balance and joint-position sense at all, and those that did began across a four-week spread rather than on a date. The canonical…”Week ruler · week 8 (tibiofemoral)“A clearance rather than a date — and a single crutch outdoors stays optional after it, because uneven ground asks more of the leg than a hallway does.”Week ruler · week 12 (tibiofemoral)“The canonical protocol stops needing the pool here and opens outdoor cycling, rowing and ellipticals in the same breath. One week carrying both halves of a change of setting.”Hard limits · stage 1 (patellofemoral)“Nothing bends the knee while it is carrying you”Hard limits · stage 2 (patellofemoral)“Loaded bending stays shallow; unloaded range does not”Hard limits · stage 1 (tibiofemoral)“Never more weight than the percentage you were given”Hard limits · stage 2 (tibiofemoral)“Full weight is a clearance, not a date”Hard limits · stage 4 (patellofemoral)“No running, no repetitive impact, until it is cleared”Hard limits · stage 4 (tibiofemoral)“No running, no repetitive impact, until it is cleared”Hard limits · stage 4 (patellofemoral)“No pivoting or cutting”Hard limits · stage 4 (tibiofemoral)“No pivoting or cutting”Why this · Why you can walk on it almost immediately, and still not bend it under load“For a patellofemoral graft the consensus allowed immediate full weight-bearing in a brace locked in extension, while staging range of motion more slowly than the tibiofemoral side …”Why this · Why so much of the first six weeks is a muscle that isn't moving“Isometric quadriceps work started at about week one in roughly half of the protocols in the practice-pattern review — the earliest and most consistently prescribed thing in this wi…”Why this · Why the quadriceps work starts before the leg is allowed to carry you“Isometric quadriceps work started at about week one in roughly half of the protocols in the practice-pattern review, alongside straight-leg raises in all planes from the early week…”Why this · Why the pool, and why deep water first“Hydrotherapy enters the canonical protocol once the wound has healed, with deep-water weight-bearing drills before shallower work.”Why this · Why depth is the thing being rationed here, and weight is not“The patellofemoral joint is barely loaded with the knee near full extension, and the load rises steeply as the knee bends under weight — which is the opposite of the tibiofemoral s…”Why this · Why depth is the thing being rationed here, and weight is not“The canonical protocol places functional squats and lunges in its return-to-work phase, later than the window this page covers, and the patellofemoral protocol located since puts i…”Why this · Why the quadriceps gets the priority, and why a lagging raise ends the set“The protocols this site cites prescribe straight-leg work as an exercise and state no standard a raise has to meet.”Why this · Why the cap here is on load, not on depth“Full active flexion is generally permitted from week six in the canonical protocol, while closed-chain work stays shallow and two-legged — load advances before depth does, which is…”Why this · Why walking normally is a milestone, and ranked above pain“The consensus panel ranked a normal gait pattern and confidence walking without crutches above pain reduction among the milestones it prioritised.”Why this · Why the arc opens in steps rather than lifting on a date“The consensus progressed patellofemoral loading by opening restricted flexion in steps rather than by lifting the restriction at a fixed point, and the canonical protocol places it…”Why this · Why this is where the real strength work starts“The canonical protocol places terminal knee extension, leg press, and functional squats and lunges in the three-to-six-month window, once full weight-bearing and a normal gait are …”Why this · Why impact is the last thing to come back, and why the two timelines disagree“The consensus placed running evaluation at six months for less complex cases and eight for more complex, with clearance at seven to nine months against ten to twelve — while the ca…”Why this · Why impact is the last thing to come back, and why the two timelines disagree“The consensus placed running evaluation at six months for less complex cases and eight for more complex, with clearance at seven to nine months against ten to twelve — while the ca…”Why this · Why impact is the last thing to come back, and why the two timelines disagree“The canonical protocol wanted hamstring and calf strength at or above ninety per cent of the other leg before that window, alongside prolonged walking and uneven ground.”Why this · Why year two is the one to watch“The canonical protocol recommends continued physical training for at least two years after surgery, on evidence carried over from the prior generation of the technique.”
Read it like a sceptic
Originally cited here from the abstract alone, disclosed at the time; the full text was obtained and read in 2026, and confirmed the conventions previously attributed to it.
One institution (Perth) wrote this protocol and much of the trial evidence behind it — internally consistent is not independently confirmed.
Population
MACI, tibiofemoral
Selection policy
Sources enter the registry through docs/research — the evidence table records design, population, and size for every entry, and pages cannot cite anything outside it.