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Introduction Half of all young adults who incur an anterior cruciate ligament rupture and subsequent reconstruction (ACLR) will develop osteoarthritis before 40 years of age. We aimed to determine the effect of a SUpervised exercise-therapy and Patient Education Rehabilitation program (SUPER) compared with minimal education on knee symptoms and cartilage health in young adults with early-onset osteoarthritis following ACLR.Materials and Methods SUPER-Knee was a prospectively registered (ACTRN12620001164987), two-armed, randomised controlled trial, which recruited young adults (18–40 years) with knee symptoms consistent with early-onset osteoarthritis 9–36 months post-ACLR. Participants were randomly assigned to: i) 4-month twice-weekly physiotherapist-supervised strengthening and neuromuscular program with education (SUPER); or ii) minimal education (one-off physiotherapist-delivered education and exercise advice). Primary outcome: Knee injury and Osteoarthritis Score (KOOS4) change at 4-months (secondary endpoint 12-months). Secondary outcome: 4- and 12-month change in MRI-derived cartilage thickness. Primary analysis was by intention-to-treat using all available data.Results 184 participants (63% male, mean±SD age 30±6years, time post-ACLR 2.3±0.7years) enrolled (92 SUPER, 92 minimal education). 178 (97%) and 174 (95%) completed 4- and 12-month outcomes, respectively. At 4-months, KOOS4 scores improved more in SUPER compared to minimal education group (14.1 vs 9.3; mean difference 4.8 [95%CI 1.4, 8.2]). The between-group difference was attenuated at 12-months (1.4 [95%CI -2.0, 4.8]). There were no between-group differences in cartilage thickness.Conclusion A supervised 4-month exercise-therapy and education program was more effective than minimal education for knee symptoms in young adults with early-onset post-traumatic osteoarthritis. Structural trajectory of knee osteoarthritis did not differ between interventions.