CLINICAL COMMENTARY

IJSPT REHABILITATION FOLLOWING MEDIAL

PATELLOFEMORAL LIGAMENT RECONSTRUCTION FOR
PATELLAR INSTABILITY
Robert C. Manske, PT, DPT, MEd, SCS, ATC, CSCS1,2,3
Daniel Prohaska, MD4,5

ABSTRACT
Patellar instability is a common problem seen by physical therapists, athletic trainers and orthopedic sur-
geons. Although following an acute dislocation, conservative rehabilitation is usually the first line of
defense; refractory cases exist that may require surgical intervention. Substantial progress has been made
in the understanding of the medial patellofemoral ligament (MPFL) and its role as the primary stabilizer to
lateral patellar displacement. Medial patellofemoral ligament disruption is now considered to be the essen-
tial lesion following acute patellar dislocation due to significantly high numbers of ruptures following this
injury. Evidence is now mounting that demonstrates the benefits of early reconstruction with a variety of
techniques. Recently rehabilitation has become more robust and progressive due to our better understand-
ing of soft tissue reconstruction and repair techniques. The purpose of this manuscript is to describe the
etiology of patellar instability, the anatomy and biomechanics and examination of patellofemoral instabil-
ity, and to describe surgical intervention and rehabilitation following MPFL rupture.
Key words: Knee, patellar instability, rehabilitation, surgery
Level of Evidence: 5

CORRESPONDING AUTHOR
Robert C. Manske, PT, DPT, MEd, SCS, ATC,
CSCS
1
Wichita State University, Wichita, KS, USA Professor and Chair
2
Via Christi Sports and Orthopedic Physical Therapy, Wichita, Wichita State University Department of
KS, USA
3
Via Christi Department of Family Medicine, University of Physical Therapy
Kansas School of Medicine Sports Medicine Fellowship 358 North Main
Program, Wichita, KS, USA
4
Advanced Orthopedic Associates, Wichita, KS, USA Wichita, KS 67202
5
University of Kansas School of Medicine, Wichita, KS, USA. E-mail: [email protected]

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 494
BACKGROUND AND PURPOSE continue to have persistent patellofemoral problems
Patellar instability is a common complaint seen by and disability and even femorapatellar osteoarthro-
physical therapists, athletic trainers and surgeons. sis.14 Risk factors for recurrent instability include
Patellar instability in athletes is a general umbrella young age, immature physes, sports-related injuries,
term used for either patellar subluxation or disloca- patella alta and trochlear dysplasia.9 Other predis-
tion.1 Dislocation and subluxations can occur due to posing factors that can contribute to chronic patel-
repetitive micro trauma over time creating a gradual lar instability include: femoral anteversion, external
progression of instability of a chronic nature. How- tibial torsion, genu valgum, patellar dysplasia, vas-
ever, instability can also occur due to an acute event tus medialis obliquus atrophy, pes plannus, and gen-
such as a patellar dislocation in which localized eralized ligamentous laxity.15
trauma has forced the patella laterally out of the safe
confines of the patellar trochlea of the distal femur. Patellar instability can be the result of multiple prob-
Lateral patellar dislocations are the most common lems including structural anatomical abnormalities,
knee dislocation injury among young adults.2 One or insufficient soft tissue restraints.16 Examples of
structure that helps maintain patellar stability is the structural abnormalities and insufficient soft tissue
medial patellofemoral ligament (MPFL). Substan- restraints include vastus medialis weakness, tight
tial progress has been made in the understanding lateral structures such as the tensor fascia lata/
of the MPFL and its role as the primary stabilizer iliotibial band, and lateral retinaculum. Other ana-
to lateral patellar displacement. MPFL disruption is tomical variations that can create this multifactorial
now considered to be the essential lesion following problem include patella alta, increased quadriceps
acute patellar dislocation due to significantly high angle, excessive tibial tubercle-trochlear groove dis-
numbers of ruptures following this injury. Evidence tance, trochlear dysplasia and ligament hyperlax-
is now mounting that demonstrates the benefits of ity.6,17-19 The purpose of this manuscript is to describe
early reconstruction with a variety of techniques. the etiology of patellar instability, the anatomy and
biomechanics and examination of patellofemoral
Actual dislocations of the patella represent a sparse instability, and to describe surgical intervention and
2%-3% of all knee injuries.3 Historically these inju- rehabilitation following MPFL rupture.
ries have occurred more commonly in females than
in males.4 Nonoperative treatment has been recom- ANATOMY
mended for this injury,5.6 however, conservative Patellar stability is afforded by both active and pas-
treatment of this condition is often of little value as sive restraints. Active restraints to the anterior knee
recurrent dislocation occurs in up to 15% to 44% of are the quadriceps muscle group. Both the rectus
patients who have sustained a traumatic patellar dis- femoris and the vastus intermedius have a direct
location.7-11 In persons who have had two prior epi- line of pull along the long axis of the femur. The
sodes of dislocations the recurrence rate jumps to vastus lateralis and the vastus medialis both have,
49%.8 Maenpaa and Lehto report that in more than although at slightly different angles, an oblique
half of the patients, a first time patellar dislocation insertion onto the patella which allows for medial
left untreated or treated nonoperatively will lead to and lateral patellar stabilization. Collectively these
instability and recurrent dislocations.12 These find- muscles provide dynamic patellofemoral stability.
ings are similar to those of McManus et al who report Passive patellar stability is provided by several soft
that the natural history of a nonoperatively treated tissue structures including the patellar tendon and
patellar dislocation involves re-dislocation in one of the patellar retinaculum. The patellar tendon is the
six cases; other residual symptoms in two of six, and distal component of the quadriceps tendon. The
three of six cases will be asymptomatic.13 Collectively patellar retinaculum is different on the lateral and
these studies indicate that conservative treatment medial sides. The lateral complex is more intricate
with a period of immobilization followed by physi- and includes two different structures: the superfi-
cal therapy is associated with re-dislocation rates of cial oblique retinaculum and the deep transverse
upwards of 63%. Those who do not re-dislocate may retinaculum.20 The medial side of the retinacular

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 495
structures are quite different and include the of the superficial medial collateral ligament.21 Feller
medial meniscopatellar ligament and the MPFL. In and colleagues report it to be anterior to the medial
the three-layer description of the medial side of the epicondyle.29 Steensen describes the origin as the
knee, the MPFL lies in the second layer.21 The MPFL actual anterior medial epicondyle,30 while multiple
was originally thought to be present in only 29%- authors report that its origin is simply at the medial
89% of knees.22,23 It is now commonly accepted that epicondyle.27,31-34
this structure is present in all knees and that it is
the major medial static stabilizer of the patellofemo- BIOMECHANICS
ral joint.24-27 Numerous studies have examined the biomechani-
The MPFL is unique in that the anterior portion inter- cal contributions and restraint provided by the
digitates with the deep fibers of the vastus medialis MPFL. Amis has shown that the native MPFL is not
obliquus (VMO) (Figure 1), suggesting that it might a very robust ligament; when compared to others
work together with the VMO supplying medial stabi- in the knee it only withstands loads of about 208N
lization. The VMO is the oblique, medial portion of when tested to failure at 25 mm of displacement.31
the quadriceps that is thought to provide dynamic The MPFL provides from 50-60% of the restraint
medial patellofemoral restraint. In concert these to lateral patellar translation during the ranges of
two structures appear to draw the patella from its 0-30 degrees of knee flexion.22,24,25 If the MPFL is
slightly lateralized position in full extension, moving sectioned, the patella displaces laterally, even with
the patella medially toward the trochlea such that the other medial stabilizers intact.25,26 Amis and col-
the patella enters the trochlea during early knee leagues suggest that this ligament is tightest near full
flexion movements.28 extension and loses tension as the knee is flexed.31
However, McCulloch et al report that the actual
The anatomical origin of the MPFL has been highest increase in strain occurred between 25-30
described in multiple locations. Warren and Mar- degrees of knee flexion.35 This may be biomechani-
shall report that the MPFL is located at the region cally appropriate as the patella generally enters the
trochlea near 15-20 degree of knee flexion and thus
has improved bony support and congruence in that
range and further into flexion.

The MPFL rupture at a mean elongation of 26 +/-7

mm in cadaveric specimens.36 Because the mean
length of the MPFL is 53 mm, ruptures occur at
approximately 49% strain.37 The average width of
the MPFL is 1.9 cm.37

TEAR CLASSIFICATION
Nomura described a classification for tears based
on surgical findings from 67 knees following acute
or recurrent patellar dislocation.38 Focal injury was
seen in 17/18 knees with acute patellar dislocation.
Figure 1. A image of the medial aspect of the right knee with These injuries were categorized into Type I and Type
the patella at the top. The MPFL, passing over the forceps, II injuries. Type I are avulsion type or detachments
links the proximal half of the medial border of the patella to of the ligament from its femoral attachment. Type
the medial femoral condyle. The superficial fascia and distal II injuries are intra-substance tears of the ligament.
part of the vastus medialis obliquus have been removed. Per-
The location of these intra-substance tears was usu-
mission granted by Mountney J, Senavongse W, Amis AA,
Thomas NP.Tensile strength of the medial patellofemoral liga- ally near the normal femoral attachment of the
ment before and after repair or reconstuction. J Bone Joint ligament. In all knees with recurrent patellar dis-
Surg. 2005;87B(1):36-40. location the MPFL was abnormal. Abnormality was

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 496
described as three different types: Type I included first time acute patellar dislocation results in sig-
no MPFL injury that was seen by gross inspection, nificant effusion in the knee. In the athlete with a
but ligament was loose at its femoral attachment; chronic recurrent dislocation the swelling and effu-
Type II consisted of scar tissue either in the body of sion may be much more subtle.
the MPFL or between the ligament and its femoral
attachment (but both are loose); Type III was termed EXAMINATION
“absent” type, in which the ligament consisted of General Examination
a remnant that lacked continuity or could not be Any evaluation of a knee disorder should be per-
identified. formed with the patient dressed in shorts with the
knees clearly exposed. Physical examination of
HISTORY patellar instability can be done in the face of an acute
As with most knee conditions, obtaining a subjec- dislocation, which will be done completely different
tive medical history is critical to the success of any than that of the athlete with a more chronic con-
evaluation of musculoskeletal injuries and is never dition. Pending the time frame between dislocation
more important than in the knee.39 The medical his- and examination the patella may still be dislocated
tory should be performed in a consistent and orderly and displaced laterally. Just because the patella
fashion with every patient in order to obtain crucial presents in its correct position it cannot be assumed
information without missing important findings.40 that it was not dislocated previously. Within several
Most patients will tell you their problems if you lis- hours of an acute dislocation, a significant effusion
ten closely and ask the appropriate questions. Acute will be present. This may limit the ability to per-
traumatic patellar dislocation can occur due to a form a thorough examination due to limited knee
single inciting incident; however subluxation of the mobility due to swelling. There will likely be tender-
patella may occur as recurrent patellar instability ness along the medial retinaculum, the MPFL and
due to repetitive minor trauma. In some instances the adductor tubercle. With these described symp-
there may not be a blow to the knee during the toms it is best to assume that the patella has been
injury mechanism. In general, patellar dislocations dislocated until proven otherwise. Swelling, range of
or subluxations occur in the lateral direction how- knee motion, palpation, and the amount of passive
ever, although rare, medial displacement can also patellar mobility should always be compared to the
occur. In most cases these injuries are the result uninvolved side. A more complete physical exam-
of a noncontact, quick turning incident, in a single ination can be performed on the suspected recur-
direction with the femur and tibia moving in oppo- rent patellar dislocation patient as they will not be
site directions. This can occur during a plant and cut as irritable as the patient with an acutely dislocated
maneuver or trying to fake someone out quickly, in patella.
which the femur internally rotates while the tibia
remains relatively externally rotated. Regardless STANDING EXAMINATION
of the mechanism, the athlete almost always feels In the standing position the patient should be
a vivid sensation of bony subluxation. The patient assessed for multiple things. Equality of weight
may describe the patella’s position grossly laterally bearing can be easily viewed in this position, as can
or just a medial prominence. Do not be fooled, as the varus and valgus alignment. An athlete with miser-
medial prominence may actually be the uncovered able malalignment syndrome (MMS) can be predis-
medial femoral condyle that can clearly be seen posed to patellar instability.40 MMS is a constellation
due the laterally displaced patella. The laterally dis- of several functional deformities which include
placed patella will stay displaced as long as the knee internal rotation of the femur, with accompanied
remains flexed. With the help of a sports physician, bayonet deformity of the tibia, external tibial tor-
athletic trainer or therapist movement of the knee sion, and pronated feet. Due to significant swelling,
into extension will usually cause an abrupt reloca- and because maximal capsular volume of the knee
tion, with which a “clunk” or shifting sensation is is in 25-30 degrees of knee flexion, the patient may
felt, providing significant pain relief. Historically a stand or walk with the knee in a flexed position.

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 497
SEATED EXAMINATION an active component by having the athlete actively
The seated examination allows the clinician to view extend their knee fully. A similar type of movement
the knee in resting position from anterior, medial should be seen if passive patellar tracking is normal.
and lateral aspect. Where is the patella sitting pas- The clinician should watch for an abrupt lateral dis-
sively in a relaxed seated position? In a patient with placement between the range of 20-30 degrees of
a large degree of patella alta the patella will be rest- flexion to full extension as the patella is deviated or
ing high and laterally in what is called “grasshopper subluxed laterally. This may be indicative of a dys-
eyes” position. Patella alta can be determined by functional vastus medialis obliquus muscle lacking
an Insall-Savalti measurement of greater than 1:1 dynamic medial stability.
ratio of patellar tendon length to patellar height. If
Strength can be tested via manual muscle testing of the
the length of the patellar tendon is greater than the
quadriceps and hamstring muscle groups while seated.
height of the patella a patella alta exists. This may
Manual muscle testing of hip muscles can be done in
predispose the athlete to recurrent patellar sublux-
supine, side lying and prone. Adequate strength of
ations or dislocations due to excessive patellar ten-
all hip muscles and musculature of the trunk/core is
don length.
needed to ensure proper proximal control.
The tibial tubercle sulcus angle can be measured
with the athlete sitting over the edge of the treat- SUPINE EXAMINATION
ment table with the knee flexed 90 degrees. The Supine examination includes examination of passive
clinician observes the position of the tibial tubercle patellar mobility, knee swelling and effusion and
relative to the patellar center. The first line, a verti- manual muscle testing of proximal hip musculature.
cal line drawn from the center of the patella while Assessment of passive patellar mobility is done in
the second is drawn from the center of the patella slight (20-30 degrees) of knee flexion, to engage the
to the tibial tubercle. The tibial tubercle should be trochlea. The patella is then passively translated in
within the femoral trochlea when the knee is flexed both the medial and lateral directions in the fron-
90 degrees. Controversy exists on what a normal tal plane (Figure 2). Patellar mobility is described
angle shoulder be, as ranges from 0 degrees to 10 in quadrants of movement. The width of the entire
degrees have been reported.41,42 patella is four quadrants. Thus two quadrants of
movement would indicate movement that is equal
Passive and active patellar tracking can also be to half the patella’s width. Normal patellar mobility
assessed in the seated position. The tripod posi- is from 1-3 quadrants of passive movement in either
tion, (leaning backwards slightly supported by both direction. Less than 1 quadrant of passive mobility
hands with a slight posterior pelvic tilt) is assumed demonstrates hypomobility while passive move-
to decrease hamstring tightness during testing. The ment greater than 3 quadrants demonstrates hyper-
clinician passively extends the relaxed patients mobility.42 Following MPFL reconstruction passive
knee from flexion to full extension. During this mobility of 2 quadrants is desirable in the medial
movement the patella translates from a slightly lat- and lateral directions.
eral position in flexion to a medial position as the
knee extends, and eventually back laterally again Swelling and joint effusion should be measured in
near full extension. Slight variations sometime exist all patients complaining of knee pain. Circumfer-
between individuals and even between right and left ential measurements can be taken at several differ-
knees of the same individual, so small deviations ent spots around the knee; In particular, measuring
should not be of great concern. As this is a passive at the joint line is suggested for generalized joint
test, it assesses osseous and non-contractive tissues. effusion. An additional location in a patient with
Excessive lateral gliding usually indicates tightness suspected patellar instability would be at an area
of the superficial retinacular fibers, whereas exces- approximately 10 cm proximal to the knee joint
sive tilting would indicate excessive deep retinacu- which is the area around the vastus medialis oblique
lar restraint. Following performance of the passive which may be selectively atrophied due to pain and
portion of this test, the clinician should examine inhibition from knee pain.

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 498
 pain, and even medial patellar instability due to iat-
rogenic causes.47-50 Indications for MPFL reconstruc-
tion include recurrent patellar instability that has
failed standard nonoperative management. The role
of MPFL reconstruction for acute patellar dislocation
and isolated trochlear dysplasia has not been clearly
determined as of the publication of this manuscript.

SURGICAL TECHNIQUE
Surgical reconstruction of the MPFL is performed in
the following steps. A thorough examination under
anesthesia is performed to assess ligament stability
and evaluate the mobility of the patella with special
attention to the lateral glide. This is checked both in
extension (Figure 3) and in flexion (Figure 4).

Diagnostic arthroscopy is performed to evaluate

the patellofemoral articular surfaces evaluating for
any chondral damage and treating as indicated (Fig-
ure 5). Patellar articular surface injury may require
debridement of loose cartilage or if severe may
require a osteochondral repair type procedure in
addition to the MPFL reconstruction.

Reconstruction of the MPFL should attempt to

reproduce the native ligament, restore normal
anatomy and function and is designed as a “check
rein”, but is not intended to be used as a harness
to hold the patella centered in the trochlea. Mul-
Figure 2. Examination of passive patellar mobility. A) The
examiner uses thumb to determine midline of patella to deter- tiple autograft choices exist including: a hamstring
mine amount of translation, B) translation of the patella in
the lateral direction assessing the amount of passive patellar
mobility. Following MPFL reconstruction the desired amount
of passive patellar mobility should be approximately 2 quad-
rants or half the width of the patella.

INDICATIONS FOR SURGERY

Conservative treatment is universally attempted in
an effort to strengthen the dynamic stabilizers of
the anterior knee. When non-operative rehabilita-
tion does not offer a satisfactory outcome regarding
stability, surgical reconstruction of the MPFL may
be offered. MPFL reconstruction has been shown to
be an acceptable method to restore static stabilizing
structures.25,43-46 Historically traditional procedures
Figure 3. Pre-operative lateral patellar displacement with
to address patellar dysfunction such as medial reti-
knee positioned in flexion. Taken from: Manske RC, Lehecka
nacular reefing or the lateral release have been uti- BJ, Prohaska D. Medial patellofemoral ligament reconstruc-
lized to address chronic patellar instability but these tion for patellar instability. SPTS Home Study Course, India-
often result in continued instability, anterior knee napolis, IN. 2010.

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 499
Figure 4. Pre-operative lateral patellar displacement with Figure 6. Location of double incisions used for MPFL recon-
knee positioned in full extension. Taken from: Manske RC, struction. Taken from: Manske RC, Lehecka BJ, Prohaska D.
Lehecka BJ, Prohaska D. Medial patellofemoral ligament recon- Medial patellofemoral ligament reconstruction for patellar
struction for patellar instability. SPTS Home Study Course, instability. SPTS Home Study Course, Indianapolis, IN. 2010.
Indianapolis, IN. 2010.

Figure 7. solating hamstring tendons used for MPFL recon-

Figure 5. Diagnostic arthroscopy demonstrating patellar struction. Taken from: Manske RC, Lehecka BJ, Prohaska D.
instability. Medial patellofemoral ligament reconstruction for patellar
instability. SPTS Home Study Course, Indianapolis, IN. 2010.

tendon,43,45 the adductor magnus,,51,52 a portion of on the far side or with an interference screw, or by
the quadriceps tendon,53,54 or a medial strip of the looping the graft through the patella with no actual
quadriceps tendon. Each of these can be used leav- fixation in the patella itself. A double incision is
ing the patellar attachment intact. Allograft tissue used for proper tunnel and graft placement (Figure
has been used, with outcomes that are acceptable, 6). When using hamstring autografts, the hamstring
including no undue risk for re-rupture, and no tendons must first be isolated and procured (Figure
donor site morbidity.55,56 7). The graft is passed between the soft tissue layers
from the patella to its position of attachment on the
The graft is secured to the patella either by tunnels medial femoral condyle making sure that the graft
passing the graft through the patella and anchoring stays outside the knee capsule.

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 500
Figure 8. After graft fixation, tension is set so that there is no Figure 9. Post-operative lateral patellar translation at 30
undue tension on the medial side. The graft should become a degrees of flexion showing excellent stability. Taken from: Man-
passive tether, not to create a medial pull. Taken from: Manske ske RC, Lehecka BJ, Prohaska D. Medial patellofemoral liga-
RC, Lehecka BJ, Prohaska D. Medial patellofemoral ligament ment reconstruction for patellar instability. SPTS Home Study
reconstruction for patellar instability. SPTS Home Study Course, Course, Indianapolis, IN. 2010.
Indianapolis, IN. 2010.

It is important to use bony landmarks and often fluo- activity level. These four phases are typical of other
roscopy is employed to ensure that the graft entrance postoperative procedures for the knee and include:
to the femur is in the correct location. After fixation Protective Phase (day one to week 6), Moderate Pro-
of the graft, tension is set so that there is no exces- tection Phase (Weeks 7 to 12), Minimum Protection
sive strain on the medial side of the knee (Figure Phase (Weeks 13 to 16), and Return to Full Activity
8). The knee is taken through full range of motion Phase (Weeks 17-20+). Because not all patients heal
to ensure that the graft does not change in length in the same speed or manner, within the descrip-
and tighten or loosen. For example, if the femoral tions of each of these postoperative phases, clinical
site is too proximal, the graft will be tight in flexion, milestones are listed which allow the clinician to
and so the tunnel needs to be repositioned. Failure better know when the patient can be progressed to
to change the tunnel may lead to a knee that has another phase.
excessive loss of flexion after reconstruction. Follow-
ing graft fixation, lateral patellar translation is again PHASE I: PROTECTIVE PHASE (DAY 1 TO
assessed to ensure proper tension (Figure 9). WEEK 6)
Goals for this initial phase following reconstruc-
Fixation on the femur can be done with interference tion include protecting the repair, decreasing pain
screw, anchors in bone, or distal button fixation. and inflammation, preventing the negative effects
of immobilization, restoring knee range of motion
Post operatively the knee is placed in a compressive
and arthrokinematics, preventing hypomobility,
soft dressing and cold therapy is utilized. Surgery is
promoting dynamic stability, preventing reflex inhi-
done on an outpatient basis.
bition and secondary muscle atrophy, developing
neuromuscular control of the knee and maintaining
REHABILITATION FOLLOWING MPFL
core stability.
RECONSTRUCTION
Return to activity following MPFL will follow a four When MPFL reconstruction is performed inde-
phase progression of rehabilitation that gradually pendently, Phase I begins within 2-3 days of the
allows an increase in range of motion and quadri- surgery. This surgical procedure can also be per-
ceps activation, in order to allow a full return to prior formed concomitantly with a lateral release or distal

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 501
realignment procedure and may require additional non-weight bearing, instructed not to exercise their
immobilization periods. knee, and were immobilized in a knee brace during
the initial postoperative weeks.65
With isolated MPFL reconstruction, ambulation is Because post-surgical pain and swelling are known
weight bearing as tolerated and range of motion is to inhibit quadriceps muscle control, both cryother-
progressed as tolerated immediately. Strict immo- apy and electrical stimulation are used to alleviate
bilization of the knee can result in loss of ground pain by decreasing nerve conduction velocity and
substance and dehydration and approximation of releasing endogenous opiates.66-70 In addition to these
embedded fibers in the extracellular matrix of soft modalities the knee should be covered with a com-
tissues.57 Because the surgical reconstruction of the pression wrap of some form. The compressive dress-
MPFL requires operating at or near the medial epi- ing could be an ace wrap or “tube grip” type wrap
condyle of the knee, early motion is indicated. Dur- to decrease existing swelling or prevent the onset of
ing flexion and extension motion at the knee there further swelling. The knee should also be kept in ele-
is substantial movement of soft tissues around the vation early over the first 1-2 days following surgery.
medial epicondyle and therefore stiffness and loss of
motion is common.58 Although some report a restric- Range of motion is initiated and progressed per sur-
tion of motion and weight bearing are required to geon’s protocol. The native intact MPFL has a load to
protect against additional soft tissue injury follow- failure rate of 208N.36,71,72 When the tibialis anterior is
ing MPFL surgery,59,60 the authors of this manuscript used as a graft substitute, its load to failure strength
suggest that immobilization is not worth the risk is 1553N,73 while a single strand of semitendinosus
of post-operative stiffness. To decrease this risk of load to failure strength is 1060N.74 Due to the strength
stiffness, range of motion is initiated progressively of substitute grafts, motion is provided to the knee
and early. Immediate range of motion as tolerated and patellofemoral joint. After an assessment of pas-
is allowed because the MPFL experiences maximal sive patellar mobility, patellar mobilizations may be
loads near full knee extension and during early knee performed in all directions. Because knee motion
flexion range of motion.28 As long as the graft is stiffness and flexion contractures are one of the top
placed isometrically, increases in knee flexion range complications following MPFL reconstruction,75 the
of motion should not place undue strain on the sub- patella can be mobilized if passive mobility is lim-
stitute tissue. Controlled mobilization reverses the ited. This is in direct opposition to Cheatham and
effects of immobilization by stimulating collagen colleagues76 who report that only grade I and II supe-
synthesis and optimizing alignment of healing tis- rior and inferior glides are performed at the patel-
sues.61,62 This is of particular concern in ligaments lofemoral joint as they feel that medial and lateral
as studies in animals have clearly shown that fol- glides may stress the surgical site. As long as fixation
lowing even a few weeks of immobilization results is appropriate concern regarding the stress of grade
in marked decreases in structural properties.63,64 III and IV patellar mobilizations is not warranted.
These decreased properties occur due to subperi- Patellar passive mobility of at least two quadrants in
osteal bone resorption within the insertion sites as both the medial and lateral directions is desired. If
well as microstructural changes within the ligament there are less than two quadrants of passive mobil-
substance. Remobilization was found to reverse the ity, joint mobilizations are instituted (Figure 10). As
changes, however it took up to one year to return with most postoperative knee procedures the first
the properties to normal levels following only nine post-operative priority is always gaining full exten-
weeks of immobilization. A systematic review of sion to decrease the risk of developing a flexion con-
eight papers of investigations following rehabilita- tracture (Figure 11). Cyclops lesions, as seen with
tion for MPFL reports that there is little differences anterior cruciate ligament reconstructions, are not
in radiological or clinical outcomes between patients commonly reported following MPFL reconstruction,
who were initially full weight bearing, began imme- however capsular and or infrapatellar fat pad con-
diate active exercises, and were not immobilized in tracture, quadriceps inhibition, and poorly placed
a knee brace, compared to those who were initially grafts can lead to motion complications.58

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 502
 full weight bearing without symptoms. Because the
hip and trunk are so important in maintaining proxi-
mal control for the knee and the patellofemoral joint,
total leg strengthening (TLS) is initiated early. A
phased approach is used to progressively strengthen
the hip. The exercises used are based on electromyo-
graphic (EMG) studies demonstrating the hierarchy
of maximal volitional contraction of the surrounding
hip musculature.77-80 Bolgla and Boling81 performed a
systematic review showing that both quadriceps and
hip strengthening exercises are helpful to reduce
pain in those with patellofemoral pain syndrome.
They are also the mainstay during MPFL rehabilita-
tion. Please see Table 1 for list of exercise in rank
Figure 10. Treatment of a hypomobile patellofemoral joint fol- order based on percentage EMG activity.
lowing MPFL reconstruction. Lack of passive mobility following If quadriceps inhibition occurs during this time frame,
reconstruction is one of the most common causes of surgical
evidence has demonstrated neuromuscular electri-
failure. If the athlete does not have a minimum of 2 quadrants
passive patellar mobility, medial and lateral glide patellofemo- cal stimulation to be helpful in reducing strength
ral joint mobilizations may be required. loss after knee ligament surgery. Neuromuscular
electrical stimulation should be performed with the
athlete’s volitional contraction in order to work opti-
mally.82-85 Empirically, the authors of this manuscript
have found that performing the quadriceps contrac-
tions in weight bearing increases contractile output
better than when performed supine in long sitting.
Because of the replacement graft immediate
strength, a brace or immobilizer is not used. Better
understanding of graft mechanics and graft loading
has resulted in advancement of rehabilitation. Basic
exercises can begin including straight leg raises in
all four planes, ankle isotonic strengthening in all
planes, heel slides, quadriceps, hamstring and glu-
teal sets and eventually isotonic hamstring curls.
Once full weight bearing is achieved without issues,
Figure 11. Obtain early full knee extension to prevent flexion closed kinetic chain exercises can begin. These
contracture. include heel raises, mini-squats, progressive step-
ups and downs, and balance and proprioception.
Clinical milestones for a safe progression at the end
The patient should ambulate weight bearing as tol-
of phase I include full non-painful knee range of
erated progressing to full weight bearing for the first
motion, full weight bearing without antalgia or limp,
two weeks. Empirically, the authors have seen that
no increase in pain or swelling, at least 2 quadrants of
typically the patient is full weight bearing within
patellar mobility, and ability to stand on a single leg.
one week, however, it is not uncommon to reserve
the second week for crutch use if needed or if pain
PHASE II: MODERATE PROTECTION PHASE
and swelling persists for a longer amount of time.
(WEEKS 7-12)
Early exercises include quadriceps sets, heel slides, Goals for the moderate protection phase include: 1)
hamstring sets and gluteal sets until the patient is maintaining full range of motion, 2) maintain repair,

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 503
 Table 1. Rank Order of Mean EMG during Exercises for Gluteus Medius and
Gluteus Maximus Muscles80
Exercise Gluteus Medius Exercise Gluteus Maximus

Side-lying hip abducon 81 Single-limb squat 59

Single-limb squat 64 Single-limb deadli 59
Lateral band walk 61 Transverse lunge 49
Single-limb deadli 58 Forward lunge 44
Sideways hop 57 Sideways lunge 41
Transverse hop 48 Side-lying hip abducon 39
Transverse lunge 48 Sideways hop 39
Forward hop 45 Clam in 60 hip flexion 30
Forward lunge 42 Transverse hop 35
Clam in 30 hip flexion 40 Forward hop 35
Sideways lunge 39 Clam in 30 hip flexion 34
Clam in 60 hip flexion 38 Lateral band walk 27
All values expressed as a % of MVIC.
Data reproduced from: Distefano LJ, Blackburn JT, Marshall SW, Padu DA. Gluteal muscle
acvaon during common therapeuc exercises. J Orthop Sports Phys Ther
2009;39(7):532-540.

3) gradual initiation of functional activities. During

this phase most restrictions have been lifted.

Range of motion should be fairly well established at

this time. If not, emphasis on motion should take
precedence so as to not end up with an arthrofi-
brotic knee. Higher grade mobilizations and gentle
overpressure to end ranges should be instituted to
normalize the arthrokinematics of knee flexion and
extension.

Exercises for strengthening in phase II can include

a progression of squats by adding weight or adding
proprioceptive component by squatting on balance
board (Figure 12). Other closed chain exercises can
include lunges starting on level ground and progress- Figure 12. Performance of squat exercise on a balance board
ing to lunging to labile surface. Leg press exercises providing not only lower extremity strengthening but also a pro-
should be performed both bilaterally (Figure 13) prioceptive and balance training effect.
and unilaterally to ensure adequate stimulus to the
post-surgical knee. Lateral band walking places sig-
regaining dynamic stability and neuromuscular con-
nificant load on the hip musculature and is a great
trol should be a priority. Neuromuscular training
exercise to progress proximal hip dynamic stability
improves the nervous systems ability to generate
and control (Figure 14).
optimal and fast muscle firing patterns, increases
Other hip exercises that are effective at strengthen- dynamic joint stability, and decreases joint reac-
ing at this time are single leg bridge (Figure 15) and tion forces, which allows the muscles surrounding
hip hiking (Figure 16 A and B). Balance and proprio- the joint to achieve a state of “readiness” to respond
ceptive exercises provide training for a stable base for to joint forces and stimulus resulting in enhanced
the rest of the body to move from. The importance motor control.85 Early forms of balance training can
of balance and proprioception in athletics cannot be begin in partial weight bearing progressing to full
denied. An attempt to regain lost proprioception, weight bearing. These can occur as weight shifting

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 504
Figure 13. Squatting on a leg press can increase the tolerable Figure 15. Hip abductors are recruited highly with the lateral
load in a controlled fashion. band walking drill.

Figure 14. Lateral band walking provides a method of incor-

porating additional strengthening effect to the hip abductors
which are important proximal stabilizers to the leg and improves
knee control.

in all directions. Squatting on a balance board or

foam pad can help challenge balance and proprio-
ception. Ultimately single-leg balance exercises can
be done by applying a light perturbation or by using
distractive elements such as throwing and catching
a ball while balancing. In this manner perturbation
training is done to induce dynamic knee stability
allowing patients to develop their own compensa-
tion strategies to maintain stability.86

Single-leg exercises can begin including single- Figure 16. A. Hip hike in the down position, B. Hip hike in the
leg squats. These should be assessed critically as up position.

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 505
compensations can occur. These compensations PHASE III: MINIMUM PROTECTION PHASE
generally result in increased hip adduction, inter- (WEEKS 13-16)
nal rotation and tibial abduction. These can be seen The minimum protection phase has the shortest
subjectively when performing a single-leg squat time frame, which lasts from 13 to 16 weeks. The
with poor control (Figure 17A). At times this can be primary goals of this phase are to gradually return
improved through strengthening exercises however the athlete to functional activities.
visual and verbal cues may help improve poor pos-
To allow a gradual return to functional and ath-
tural control (Figure 17B). The clinical milestones
letic activities the involved knee has to have loads
for the moderate protection phase are to maintain
gradually applied up to that of the level needed to
previous milestones and to have full strength of hip,
perform these higher functional activities such
quadriceps and hamstrings. These milestones are
as running and jumping. This can be achieved by
important to be able to tolerate higher level activi-
ensuring adequate strength through increased resis-
ties in the minimum protection phase.
tance and intensity during previous exercises such
as squats, lunges, and leg press. Plyometric activities
can begin with small bounding bilaterally such as
double- leg jumping in place or double- leg jump-
ing across multiple planes (Figure 18). Lateral and
medial bounding can also be initiated which places
specific stressors to the medial and lateral knee. Pro-
gressions of jumping/hopping should always start
bilateral (jumping) and progressing to unilateral
(hopping). Progressions to single-leg hopping are
initiated in the next phase.

Clinical milestones to move into phase IV include

all the prior milestones in addition to confidence in
knee.

PHASE IV: RETURN TO ACTIVITY (WEEKS

17-21+)
Goals for the return to activity phase include 1) pro-
gression of functional activities, 2) full return to all

Figure 17. A. Single-leg squat can be performed to examine

more functional movement patterns of the entire lower extrem-
ity. A) The patient demonstrates poor frontal, transverse and
sagittal control. B) improved control is assisted by visualization
in front of mirror and verbal cues. Figure 18. Bilateral jumping without pain or symptoms.

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 506
prior sports or recreational activities. In this goal flexibility) compared to those with good movement
the athlete is challenged at even higher levels of qualities.88
lower leg stressors that will determine if they are
Additionally, jumping and hopping tests are used.
able to return to their prior sporting activities. This
Criteria to be released for return to sports are for the
level may not be utilized for every patient. Not all
athlete to be able to jump with both legs together
patients that have MPFL reconstruction are higher-
horizontally 100% of height for males and 90% of
level athletes. If they do not desire or require this
height for females. Single-leg hop distances should
level of activity they would not be required to be
be 90% of height for males and 80% of height for
rehabilitated to this level.
females. These are standardized norms for healthy
Once the athlete is comfortable with bilateral jump- non injured populations.89
ing they can attempt unilateral single-leg hopping Nomura and colleagues90 followed 24 knees with
on one foot. To start, it may be best to hop off of sin- after MPFL reconstruction for a mean follow-up of
gle affected side and landing on the unaffected side. 11.9 years. Using the Crosby/Insall criteria and Kell-
Athletes following knee surgery are usually more gren/Lawrence grading systems and found that the
able to hop from the surgical leg concentrically, but association of knee osteoarthritis following MPFL
more concerned or afraid when asked to land eccen- reconstruction with or without a lateral release
trically on the affected single-leg. Functional drills was small over the long-term. This is important as
or activities such as sidestepping, ladder drills, or other surgical treatments such as proximal or distal
carioca can be done in a controlled manner to work realignments has been proven to be associated with
on neuromuscular control. It is also at this last stage osteoarthritis as early as 10 years following the pro-
that the athlete can begin interval type programs cedure.91-96 Furthermore, Lippacher and colleagues
such as return to running program. found that of those who participated in sports prior
to MPFL reconstruction, 100% returned to sports.97
DISCHARGE AND FULL RETURN TO Fifty-three percent returned to equal or higher lev-
COMPETITION els, whereas 47% returned at lower levels. In those
Discharge and full release and return to competitive that returned to lower levels of athletics numer-
sports is based on criteria that include: full range of ous reasons were cited including physical reasons
motion, full strength and ability to achieve norms such as decreased knee function and desire to avoid
on standardized functional tests. The single leg excessive sports after surgery, but also more psycho-
step down test should be able to be performed with logical reasons too such as lack of time or interest
good form.87 This test is performed with the patient and the fact that they were advised to be aware of
standing near the edge of a 20cm step. The patient the risks of high-pivot sports such as soccer.
is asked to place hands on hips and flex the test
knee enough to touch the floor gently with opposite PATIENT REPORTED OUTCOMES
extremity. Five repetitions are scored by giving a Patient reported outcomes are instruments and
single point for 1) using arms to maintain balance, 2) rating scales used to measure outcomes from the
trunk lean either medial or lateral, 3) pelvis rotation patient’s perspective. These outcomes may at times
or elevation, 4) tibial tubercle moving medial to 2nd be very different from our clinical objective mea-
toe, 5) unsteady unilateral stance; while two points sures. These outcome tools examine many facets of
are given for the tibial tubercle moving medial to knee health including swelling, giving way, pain and
the foot. A good score is needed to return to sports. ability to function in activities of daily living. The
A good quality score is 0-1 point, medium quality is authors of this manuscript recommend several fol-
2-3 points, and poor quality is 4+ points. The step lowing MPFL reconstruction. The Activities of Daily
down test has been shown to have good interrater Living Scale98 and the Sports Activity Scale99 are both
reliability and has the ability to differentiate those knee specific. The Sports Activity Scale have ques-
with moderate quality of movement (those with less tions more related to higher levels of physical activ-
hip abduction strength and decreased quadriceps ity that are pertinent in active populations.

The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 507
CONCLUSIONS 9. Lewallen L, McIntosh A, Dahm D. First-time
The science behind MPFL reconstruction and the patellofemoral dislocation: risk factors for recurrent
ensuing rehabilitating continue to evolve as more instability. J Knee Surg; 2015; 28(4):303-310.
evidence becomes available. The suggested proto- 10. Mehta VM, Inoue M, Nomura E, et al. An algorithm
guiding the evaluation and treatment of acute
col will help guide the patient to full recovery to
primary patellar dislocations. Sports Med Arthrosc.
sports and/or recreational activities without com- 2007;15(2):78-81.
plications. An early emphasis on range of motion 11. Trikha SP, Acton D, O’Reilly M, et al. Acute lateral
followed by a progression of strengthening exercises dislocation of the patella: correlation of ultrasound
allows adequate incorporation of the soft tissue graft scanning with operative findings. Injury
to the bony structures utilized during this recon- 2003;34(8):568-571.
struction. Clinical milestones have been described 12. Maenpaa H, Lehto MU. Patellar dislocation. The
to demonstrate when movement to the next phase long-term results of nonoperative management in
100 patients. Am J Sports Med. 1997;25:213-217.
is to be performed. MPFL reconstruction has been
shown to have good results with low risk for major 13. McManus F, Rang M, Heslin DJ. Acute dislocation of
the patella in children: The natural history. Clin Res.
complications. As the surgery and the understand- 1979;139:88-91.
ing of the MPFL continue to evolve so will the reha-
14. Hawkins RJ, Bell RH, Anisette G. Acute patellar
bilitation that follows. At present, clinicians must dislocations: The natural history. Am J Sports Med.
respect the soft healing tissue constraints but not at 1986;14:117-120.
the expense of stiffness. Certainly higher levels of 15. Reagan J, Kullar R, Burks R. MPFL reconstruction.
clinical research with longer follow up are needed Technique and results. Clin Sports Med. 2014;33:501-516.
to fully investigate the outcomes following this 16. Lind M, Jakobsen BW, Lund B, Christiansen SE.
procedure. Reconstruction of the medial patellofemoral
ligament for treatment of patellar instability. Acta
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The International Journal of Sports Physical Therapy | Volume 12, Number 3 | June 2017 | Page 511