Skip to main content

Rehabilitation before regenerative cartilage knee surgery: a new prehabilitation guideline based on the best available evidence



Focal cartilage defects are an increasingly relevant clinical problem especially in athletes. Cartilage regenerative surgery (CRS) including microfracture and autologous chondrocyte implantation (ACI) to treat such isolated cartilage defects in the knee joint has been well established in the last two decades. In contradiction to high-level evidence concerning the surgical technique, cell-related issues, and clinical results, the knowledge about the optimal rehabilitation process is still sparse although the importance of optimizing the rehabilitation process has recently led to new research focus in this field. The preoperative time frame may be used to start rehabilitation which may fasten the postoperative recovery and optimize clinical outcome (“Prehabilitation”—PREHAB). The aim of this article, therefore, was to review the available literature on prehabilitation concepts and to present a prehabilitation guideline for CRS patients based on the best evidence available.


A systemic literature research was conducted on rehabilitation for cartilage regenerative surgery as well as prehabilitation in knee joint procedures. From the available literature a prehabilitation concept was generated and tested in 10 ACI patients.


As the literature search found no studies addressing prehabilitation in CRS patients, an evidence-based PREHAB program has been compiled based on the available evidence from (a) studies addressing postoperative rehabilitation in CRS patients and (b) PREHAB studies on other knee procedures including TKA. This presented prehabilitation guideline has been tested in > 50 CRS patients and was found to be feasible as all of the patients showed a good compliance and were able to perform the protocol as suggested.


The presented PREHAB regimen may serve clinicians as a guideline for early rehabilitation of their CRS patients. Obviously, further research is mandatory to quantify its clinical effect and to demonstrate its cost-effectiveness and benefits in surgically treated patients.

This is a preview of subscription content, access via your institution.


  1. 1.

    Campbell AB, Pineda M, Harris JD, Flanigan DC (2016) Return to sport after articular cartilage repair in athletes’ knees: a systematic review. Arthroscopy 32(4):651–668 e651.

    Article  Google Scholar 

  2. 2.

    Flanigan DC, Harris JD, Trinh TQ, Siston RA, Brophy RH (2010) Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc 42(10):1795–1801.

    Article  Google Scholar 

  3. 3.

    Niemeyer P, Lenz P, Kreuz PC, Salzmann GM, Suedkamp NP, Schmal H, Steinwachs M (2010) Chondrocyte—seeded collagen type I/III membrane (ACT-CS) for autologous chondrocyte transplantation: Prospective 2-year results in patients with cartilage defects of the knee joint. Arthroscopy (in print)

  4. 4.

    Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A (2002) Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med 30(1):2–12

    Article  PubMed  Google Scholar 

  5. 5.

    Peterson L, Vasiliadis HS, Brittberg M, Lindahl A (2010) Autologous chondrocyte implantation: a long-term follow-up. Am J Sports Med 38(6):1117–1124.

    Article  Google Scholar 

  6. 6.

    Saris DB, Vanlauwe J, Victor J, Almqvist KF, Verdonk R, Bellemans J, Luyten FP (2009) Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med 37(Suppl 1):10S–19S.

    Article  Google Scholar 

  7. 7.

    DiBartola AC, Wright BM, Magnussen RA, Flanigan DC (2016) Clinical outcomes after autologous chondrocyte implantation in adolescents’ knees: a systematic review. Arthroscopy.

    Article  PubMed  Google Scholar 

  8. 8.

    Krishnan SP, Skinner JA, Bartlett W, Carrington RW, Flanagan AM, Briggs TW, Bentley G (2006) Who is the ideal candidate for autologous chondrocyte implantation? J Bone Jt Surg Br 88(1):61–64.

    Article  CAS  Google Scholar 

  9. 9.

    Mithofer K, Minas T, Peterson L, Yeon H, Micheli LJ (2005) Functional outcome of knee articular cartilage repair in adolescent athletes. Am J Sports Med 33(8):1147–1153.

    Article  PubMed  Google Scholar 

  10. 10.

    Hambly K, Bobic V, Wondrasch B, Van Assche D, Marlovits S (2006) Autologous chondrocyte implantation postoperative care and rehabilitation: science and practice. Am J Sports Med 34(6):1020–1038.

    Article  PubMed  Google Scholar 

  11. 11.

    Ebert JR, Ackland TR, Lloyd DG, Wood DJ (2008) Accuracy of partial weight bearing after autologous chondrocyte implantation. Arch Phys Med Rehabil 89(8):1528–1534.

    Article  PubMed  Google Scholar 

  12. 12.

    Della Villa S, Kon E, Filardo G, Ricci M, Vincentelli F, Delcogliano M, Marcacci M (2010) Does intensive rehabilitation permit early return to sport without compromising the clinical outcome after arthroscopic autologous chondrocyte implantation in highly competitive athletes? Am J Sports Med 38(1):68–77.

    Article  Google Scholar 

  13. 13.

    Wondrasch B, Aroen A, Rotterud JH, Hoysveen T, Bolstad K, Risberg MA (2013) The feasibility of a 3-month active rehabilitation program for patients with knee full-thickness articular cartilage lesions: the Oslo Cartilage Active Rehabilitation and Education Study. J Orthop Sports Phys Ther 43(5):310–324.

    Article  PubMed  Google Scholar 

  14. 14.

    Ebert JR, Lloyd DG, Wood DJ, Ackland TR (2012) Isokinetic knee extensor strength deficit following matrix-induced autologous chondrocyte implantation. Clin Biomech 27(6):588–594.

    Article  Google Scholar 

  15. 15.

    Loken S, Ludvigsen TC, Hoysveen T, Holm I, Engebretsen L, Reinholt FP (2009) Autologous chondrocyte implantation to repair knee cartilage injury: ultrastructural evaluation at 2 years and long-term follow-up including muscle strength measurements. Knee Surg Sports Traumatol Arthrosc 17(11):1278–1288.

    Article  PubMed  Google Scholar 

  16. 16.

    Kreuz PC, Muller S, Erggelet C, von Keudell A, Tischer T, Kaps C, Niemeyer P, Hirschmuller A (2014) Is gender influencing the biomechanical results after autologous chondrocyte implantation? Knee Surg Sports Traumatol Arthrosc 22(1):72–79.

    Article  PubMed  Google Scholar 

  17. 17.

    Kreuz PC, Muller S, Freymann U, Erggelet C, Niemeyer P, Kaps C, Hirschmuller A (2011) Repair of focal cartilage defects with scaffold-assisted autologous chondrocyte grafts: clinical and biomechanical results 48 months after transplantation. Am J Sports Med 39(8):1697–1705.

    Article  PubMed  Google Scholar 

  18. 18.

    Kreuz PC, Steinwachs M, Erggelet C, Lahm A, Krause S, Ossendorf C, Meier D, Ghanem N, Uhl M (2007) Importance of sports in cartilage regeneration after autologous chondrocyte implantation: a prospective study with a 3-year follow-up. Am J Sports Med 35(8):1261–1268.

    Article  Google Scholar 

  19. 19.

    Slemenda C, Brandt KD, Heilman DK, Mazzuca S, Braunstein EM, Katz BP, Wolinsky FD (1997) Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med 127(2):97–104

    Article  CAS  Google Scholar 

  20. 20.

    Slemenda C, Heilman DK, Brandt KD, Katz BP, Mazzuca SA, Braunstein EM, Byrd D (1998) Reduced quadriceps strength relative to body weight: a risk factor for knee osteoarthritis in women? Arthritis Rheum 41 (11):1951–1959.;2-9

    Article  CAS  PubMed  Google Scholar 

  21. 21.

    Bennell K, Hinman RS, Wrigley TV, Creaby MW, Hodges P (2011) Exercise and osteoarthritis: cause and effects. Compr Physiol 1(4):1943–2008.

    Article  PubMed  Google Scholar 

  22. 22.

    Jackson BD, Wluka AE, Teichtahl AJ, Morris ME, Cicuttini FM (2004) Reviewing knee osteoarthritis—a biomechanical perspective. J Sci Med Sport 7(3):347–357

    Article  CAS  PubMed  Google Scholar 

  23. 23.

    Jan MH, Lin DH, Lin JJ, Lin CH, Cheng CK, Lin YF (2009) Differences in sonographic characteristics of the vastus medialis obliquus between patients with patellofemoral pain syndrome and healthy adults. Am J Sports Med 37(9):1743–1749.

    Article  PubMed  Google Scholar 

  24. 24.

    Bennell KL, Kyriakides M, Metcalf B, Egerton T, Wrigley TV, Hodges PW, Hunt MA, Roos EM, Forbes A, Ageberg E, Hinman RS (2014) Neuromuscular versus quadriceps strengthening exercise in patients with medial knee osteoarthritis and varus malalignment: a randomized controlled trial. Arthritis Rheumatol 66(4):950–959.

    Article  PubMed  Google Scholar 

  25. 25.

    Cashman GE (2012) The effect of weak hip abductors or external rotators on knee valgus kinematics in healthy subjects: a systematic review. J Sport Rehabil 21(3):273–284

    Article  PubMed  Google Scholar 

  26. 26.

    Kean CO, Hinman RS, Wrigley TV, Lim BW, Bennell KL (2017) Impact loading following quadriceps strength training in individuals with medial knee osteoarthritis and varus alignment. Clin Biomech 42:20–24.

    Article  Google Scholar 

  27. 27.

    Kean CO, Bennell KL, Wrigley TV, Hinman RS (2015) Relationship between hip abductor strength and external hip and knee adduction moments in medial knee osteoarthritis. Clin Biomech (Bristol Avon) 30(3):226–230.

    Article  Google Scholar 

  28. 28.

    Cronin B, Johnson ST, Chang E, Pollard CD, Norcross MF (2016) Greater Hip extension but not hip abduction explosive strength is associated with lesser hip adduction and knee valgus motion during a single-leg jump-cut. Orthop J Sports Med 4(4):2325967116639578.

    Article  PubMed  PubMed Central  Google Scholar 

  29. 29.

    Costa RA, Oliveira LM, Watanabe SH, Jones A, Natour J (2010) Isokinetic assessment of the hip muscles in patients with osteoarthritis of the knee. Clinics 65(12):1253–1259

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    van Gool CH, Penninx BW, Kempen GI, Rejeski WJ, Miller GD, van Eijk JT, Pahor M, Messier SP (2005) Effects of exercise adherence on physical function among overweight older adults with knee osteoarthritis. Arthritis Rheum 53(1):24–32.

    Article  PubMed  Google Scholar 

  31. 31.

    Mazieres B, Thevenon A, Coudeyre E, Chevalier X, Revel M, Rannou F (2008) Adherence to, and results of, physical therapy programs in patients with hip or knee osteoarthritis. Development of French clinical practice guidelines. Jt Bone Spine 75(5):589–596.

    Article  Google Scholar 

  32. 32.

    Ibrahim MS, Khan MA, Nizam I, Haddad FS (2013) Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review. BMC Med 11:37.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Santa Mina D, Clarke H, Ritvo P, Leung YW, Matthew AG, Katz J, Trachtenberg J, Alibhai SM (2014) Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy 100(3):196–207.

    Article  CAS  PubMed  Google Scholar 

  34. 34.

    Jaggers JR, Simpson CD, Frost KL, Quesada PM, Topp RV, Swank AM, Nyland JA (2007) Prehabilitation before knee arthroplasty increases postsurgical function: a case study. J Strength Condition Res Natl Strength Condition Assoc 21(2):632–634.

    Article  Google Scholar 

  35. 35.

    Topp R, Swank AM, Quesada PM, Nyland J, Malkani A (2009) The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty. J Injury Funct Rehabil 1(8):729–735.

    Article  Google Scholar 

  36. 36.

    Santa Mina D, Scheede-Bergdahl C, Gillis C, Carli F (2015) Optimization of surgical outcomes with prehabilitation. Appl Physiol Nutr Metab 40 (9):966–969.

    Article  PubMed  Google Scholar 

  37. 37.

    Ackerman IN, Bennell KL (2004) Does pre-operative physiotherapy improve outcomes from lower limb joint replacement surgery? A systematic review. Aust J Physiother 50(1):25–30

    Article  PubMed  Google Scholar 

  38. 38.

    Gill SD, McBurney H (2013) Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil 94(1):164–176.

    Article  PubMed  Google Scholar 

  39. 39.

    Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL (2015) Exercise for osteoarthritis of the knee: a Cochrane systematic review. Br J Sports Med 49(24):1554–1557.

    Article  Google Scholar 

  40. 40.

    McKay C, Prapavessis H, Doherty T (2012) The effect of a prehabilitation exercise program on quadriceps strength for patients undergoing total knee arthroplasty: a randomized controlled pilot study. J Injury Funct Rehabil 4(9):647–656.

    Article  Google Scholar 

  41. 41.

    Kean CO, Birmingham TB, Garland SJ, Bryant DM, Giffin JR (2011) Preoperative strength training for patients undergoing high tibial osteotomy: a prospective cohort study with historical controls. J Orthop Sports Phys Ther 41(2):52–59.

    Article  PubMed  Google Scholar 

  42. 42.

    Heir S, Nerhus TK, Rotterud JH, Loken S, Ekeland A, Engebretsen L, Aroen A (2010) Focal cartilage defects in the knee impair quality of life as much as severe osteoarthritis: a comparison of knee injury and osteoarthritis outcome score in 4 patient categories scheduled for knee surgery. Am J Sports Med 38(2):231–237.

    Article  Google Scholar 

  43. 43.

    Felson DT, Gross KD, Nevitt MC, Yang M, Lane NE, Torner JC, Lewis CE, Hurley MV (2009) The effects of impaired joint position sense on the development and progression of pain and structural damage in knee osteoarthritis. Arthritis Rheum 61(8):1070–1076.

    Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Hirschmuller A, Andres T, Schoch W, Baur H, Konstantinidis L, Sudkamp NP, Niemeyer P (2017) Quadriceps strength in patients with isolated cartilage defects of the knee: results of isokinetic strength measurements and their correlation with clinical and functional results. Orthop J Sports Med 5(5):2325967117703726.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Aagaard P (2003) Training-induced changes in neural function. Exerc Sport Sci Rev 31(2):61–67

    Article  PubMed  Google Scholar 

  46. 46.

    Aagaard P, Andersen JL, Dyhre-Poulsen P, Leffers AM, Wagner A, Magnusson SP, Halkjaer-Kristensen J, Simonsen EB (2001) A mechanism for increased contractile strength of human pennate muscle in response to strength training: changes in muscle architecture. J Physiol 534(Pt. 2):613–623

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. 47.

    American College of Sports Medicine Position Stand (2009) Progression models in resistance training for healthy adults. Med Sci Sports Exerc 41(3):687–708.

    Article  Google Scholar 

  48. 48.

    Ronnestad BR, Hansen J, Hollan I, Ellefsen S (2015) Strength training improves performance and pedaling characteristics in elite cyclists. Scand J Med Sci Sports 25(1):e89–e98.

    Article  CAS  PubMed  Google Scholar 

  49. 49.

    Daehlin TE, Haugen OC, Haugerud S, Hollan I, Raastad T, Ronnestad BR (2016) Combined plyometric and strength training improves Ice-Hockey players’ on-ice sprint. Int J Sports Physiol Perform.

    Article  PubMed  Google Scholar 

  50. 50.

    Gruber M, Bruhn S, Gollhofer A (2006) Specific adaptations of neuromuscular control and knee joint stiffness following sensorimotor training. Int J Sports Med 27(8):636–641

    Article  CAS  PubMed  Google Scholar 

  51. 51.

    Bruhn S, Kullmann N, Gollhofer A (2006) Combinatory effects of high-intensity-strength training and sensorimotor training on muscle strength. Int J Sports Med 27(5):401–406

    Article  CAS  PubMed  Google Scholar 

  52. 52.

    Bruhn S, Kullmann N, Gollhofer A (2004) The effects of a sensorimotor training and a strength training on postural stabilisation, maximum isometric contraction and jump performance. Int J Sports Med 25(1):56–60

    Article  CAS  PubMed  Google Scholar 

  53. 53.

    Behm D, Colado JC (2012) The effectiveness of resistance training using unstable surfaces and devices for rehabilitation. Int J Sports Phys Ther 7(2):226–241

    PubMed  PubMed Central  Google Scholar 

  54. 54.

    Hirschmuller A, Baur H, Braun S, Kreuz PC, Sudkamp NP, Niemeyer P (2011) Rehabilitation after autologous chondrocyte implantation for isolated cartilage defects of the knee. Am J Sports Med 39(12):2686–2696.

    Article  PubMed  Google Scholar 

  55. 55.

    Escamilla RF (2001) Knee biomechanics of the dynamic squat exercise. Med Sci Sports Exerc 33:127–141

    Article  CAS  PubMed  Google Scholar 

  56. 56.

    Andersen LL, Magnusson SP, Nielsen M, Haleem J, Poulsen K, Aagaard P (2006) Neuromuscular activation in conventional therapeutic exercises and heavy resistance exercises: implications for rehabilitation. Phys Ther 86(5):683–697

    PubMed  Google Scholar 

  57. 57.

    Rutherford OM, Jones DA (1986) The role of learning and coordination in strength training. Eur J Appl Physiol Occup Physiol 55(1):100–105

    Article  CAS  PubMed  Google Scholar 

  58. 58.

    Pollock ML, Gaesser GA, Butcher JD, Desprs J-P, Dishman RK, Franklin BA, Garber CE (1998) ACSM position stand: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 30(6):975–991

    Google Scholar 

  59. 59.

    Ronnestad BR, Hansen J, Hollan I, Spencer M, Ellefsen S (2016) Impairment of Performance variables after in-season strength-training cessation in elite cyclists. Int J Sports Physiol Perform 11(6):727–735.

    Article  PubMed  Google Scholar 

  60. 60.

    Wilkerson GB, Giles JL, Seibel DK (2012) Prediction of core and lower extremity strains and sprains in collegiate football players: a preliminary study. J Athl Train 47(3):264–272.

    Article  PubMed  PubMed Central  Google Scholar 

  61. 61.

    Shi DL, Li JL, Zhai H, Wang HF, Meng H, Wang YB (2012) Specialized core stability exercise: a neglected component of anterior cruciate ligament rehabilitation programs. J Back Musculoskelet Rehabil 25(4):291–297.

    Article  PubMed  Google Scholar 

  62. 62.

    Leetun DT, Ireland ML, Willson JD, Ballantyne BT, Davis IM (2004) Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc 36(6):926–934

    Article  Google Scholar 

  63. 63.

    Willson JD, Dougherty CP, Ireland ML, Davis IM (2005) Core stability and its relationship to lower extremity function and injury. J Am Acad Orthop Surg 13(5):316–325

    Article  PubMed  Google Scholar 

  64. 64.

    Eckstein F, Hudelmaier M, Putz R (2006) The effects of exercise on human articular cartilage. J Anat 208(4):491–512.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. 65.

    Eckstein F, Lemberger B, Gratzke C, Hudelmaier M, Glaser C, Englmeier KH, Reiser M (2005) In vivo cartilage deformation after different types of activity and its dependence on physical training status. Ann Rheum Dis 64(2):291–295.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. 66.

    Myer GD, Ford KR, McLean SG, Hewett TE (2006) The effects of plyometric versus dynamic stabilization and balance training on lower extremity biomechanics. Am J Sports Med 34(3):445–455.

    Article  PubMed  Google Scholar 

  67. 67.

    Nagano Y, Ida H, Akai M, Fukubayashi T (2011) Effects of jump and balance training on knee kinematics and electromyography of female basketball athletes during a single limb drop landing: pre-post intervention study. Sports Med Arthrosc Rehabil Ther Technol 3(1):14.

    Article  PubMed  PubMed Central  Google Scholar 

  68. 68.

    Steffen K, Emery CA, Romiti M, Kang J, Bizzini M, Dvorak J, Finch CF, Meeuwisse WH (2013) High adherence to a neuromuscular injury prevention programme (FIFA 11+) improves functional balance and reduces injury risk in Canadian youth female football players: a cluster randomised trial. Br J Sports Med 47(12):794–802.

    Article  PubMed  Google Scholar 

  69. 69.

    Barengo NC, Meneses-Echavez JF, Ramirez-Velez R, Cohen DD, Tovar G, Bautista JE (2014) The impact of the FIFA 11 + training program on injury prevention in football players: a systematic review. Int J Environ Res Public Health 11(11):11986–12000.

    Article  PubMed  PubMed Central  Google Scholar 

  70. 70.

    Pisters MF, Veenhof C, Schellevis FG, Twisk JW, Dekker J, De Bakker DH (2010) Exercise adherence improving long-term patient outcome in patients with osteoarthritis of the hip and/or knee. Arthritis Care Res 62(8):1087–1094.

    Article  Google Scholar 

  71. 71.

    Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE (2013) Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med 41(7):1549–1558.

    Article  PubMed  Google Scholar 

Download references


The authors are grateful to the two professional translators Carole Cürten and Duncan Cummins for language support as well as to the medical students Tanja Papke and Tasja Andrees for their support in improving the program and collegiality.


There is no funding source.

Author information



Corresponding author

Correspondence to Heiner Baur.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Appendix: Prehabilitation program

Appendix: Prehabilitation program

Warm up

Fig. 1

Stationary bike

See Figs. 1 and 2.

Fig. 2


Sensorimotor exercises

See Figs. 3, 4, 5, 6, 7, 8, 9, 10 and 11.

Fig. 3

Bench alternate legs

Fig. 4

Sideway bench static

Fig. 5

Single-leg toe touch

Fig. 6

Single-leg toe touch adding an Airex® pad

Fig. 7


Fig. 8

Squats with toe raise

Fig. 9


Fig. 10

Vertical jumps

Fig. 11

Side to side-bounds

Strength training

See Figs. 12, 13, 14, 15 and 16

Fig. 12

One-leg leg press (45° position)

Fig. 13

One-leg leg curl: leg extension

Fig. 14

One-leg leg curl: leg flexion

Fig. 15

Nordic hamstrings

Fig. 16

Hip abduction with pulley resistance

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hirschmüller, A., Schoch, W., Baur, H. et al. Rehabilitation before regenerative cartilage knee surgery: a new prehabilitation guideline based on the best available evidence. Arch Orthop Trauma Surg 139, 217–230 (2019).

Download citation


  • Knee injuries
  • Knee osteoarthritis
  • Articular cartilage
  • Rehabilitation
  • Resistance training