ORIF Knee Physical Therapy: The Rehab Protocol After Fracture Fixation
Physio after knee fracture surgery has one unusual constraint: for the first weeks, the bone — not the muscles — decides what you're allowed to do. Here's how I structure rehab around that, phase by phase.
What is ORIF knee physical therapy?
ORIF (open reduction, internal fixation) surgery fixes a broken bone around the knee with plates and screws. The physical therapy that follows is a phased programme with four jobs:
- Protect the repair while bone unites
- Keep the joint moving so it doesn't stiffen
- Rebuild the muscle that vanishes frighteningly fast
- Restore walking, stairs, work and sport in that order
Every programme is bounded by the surgeon's weight-bearing and range-of-motion orders. Physios progress you within those rules; we never override them.
The ORIF knee rehab protocol at a glance
This is the rehabilitation protocol the rest of the page unpacks. Timescales assume an uncomplicated fracture and your surgeon's standard weight-bearing orders — theirs always win:
| Phase | Timescale | Priorities | Key exercises |
|---|---|---|---|
| 1 — Protect & preserve | Weeks 0–6 | Swelling control; quads switched on; range within limits | Ankle pumps, static quads, straight-leg raises, heel slides as permitted |
| 2 — Reload | Weeks 6–12 | Graded weight-bearing; normal gait; range towards full | Sit-to-stands, mini squats, calf raises, static bike |
| 3 — Rebuild | Months 3–6 | Progressive strength; single-leg control | Leg press, step-ups, bridges, hamstring and glute work, balance drills |
| 4 — Return | Months 6+ | Impact tolerance; sport-specific confidence | Hops → jogging → running → change of direction |
The four phases I use
Phase 1 — Protect and preserve (weeks 0–6)
- Swelling control: elevation, ice, ankle pumps — hourly, not occasionally.
- Quads activation: static quads and straight-leg raises (if permitted). A quad that stays "on" through this phase saves you a month later.
- Range within limits: heel slides or brace-limited bending as prescribed.
- Everything else: keep the hip, ankle and other leg strong — you'll need them.
Phase 2 — Reload (weeks 6–12)
- Graded weight-bearing per protocol: two crutches → one → none, watching gait quality obsessively.
- Closed-chain basics: sit-to-stands, mini squats, calf raises, static bike.
- Range pushed towards full — flexion usually needs deliberate work after weeks in a brace.
Phase 3 — Rebuild (months 3–6)
- Progressive resistance: leg press, step-ups, bridges, hamstring work, glute strengthening.
- Balance and control: single-leg stance to reactive balance work.
- Milestone I want here: single-leg sit-to-stand from a chair, both sides comparable.
Phase 4 — Return (months 6+)
- Impact reintroduction — hops before jogging, jogging before running, straight lines before pivots.
- Criteria beat calendars: strength within ~10% of the other leg and confident hopping before sport. The logic mirrors ACL reconstruction rehab.
Common misconceptions I see in my patients
- "I can't do anything while non-weight-bearing." Wrong — this phase decides how far behind you start. Upper body, opposite leg, core and permitted knee range are all trainable from week one.
- "Physio is what happens in the clinic." The clinic sets the programme; the results come from the daily doses at home.
- "Pain means the metalwork is loose." Metalwork problems are uncommon; deconditioned muscle grumbling under new load is near-universal. Sharp, localised, worsening pain over the plate is what warrants a review.
FAQ: ORIF knee physical therapy
When does physical therapy start after knee ORIF?
Usually within the first week or two — sometimes day one in hospital. Early physio is about swelling, quads activation and safe movement, not loading. See the full recovery timeline for how the phases map to the calendar.
How often should I do my exercises?
Early phase: little and often, most waking hours. Strength phases: 3–4 formal sessions weekly with daily walking. Consistency beats heroics in every fracture rehab I've supervised.
Why is my knee still stiff months after ORIF?
Weeks of protection plus scar tissue make stiffness the most common leftover. It usually responds to persistent, graded range work — but a knee that's losing range, or stuck well short of 90°, should go back to the surgical team.