Patellar Realignment with MPFL Reconstruction (UVA)

*Progression is based on healing, functional progression and is specific to each patient. Phases and time frames are designed to give the clinician a general sense of progression. Many things will affect your recovery, including chronicity of injury and concomitant procedures such as cartilage procedures, lateral release, and tibial tubercle transfer among others.

PHASE I: PROTECTION PHASE (WEEKS 0-6)

GOALS:
• Independence in home therapeutic exercise (HEP) program
• Promote healing
• Control post-operative pain / swelling
• Prevent quadriceps inhibition: fair to good quadriceps contraction
• Straight leg raise (SLR) without lag, pain-free
• ROM: 0° KE to ≥ 90° KF
• 50% WB for first 6 weeks

PRECAUTIONS:
• Avoid ambulation without brace for first 6 weeks, avoid full weight bearing for first 6 weeks
• Avoid lateralization of patella
• Avoid AA-AROM KE, especially with significant quad atrophy, and articular cartilage injury
• Avoid symptom provocation: it leads to quadriceps shut down, joint effusion, active inflammation
• Follow KF ROM as per surgeon’s guidelines as below

TREATMENT RECOMMENDATIONS:
• Emphasize patient compliance to HEP and weight bearing precautions/progression
o 50% WB for first 6weeks
o ROM: in brace 0-70 for first 2weeks, 0-90 for weeks 2-4, brace unlocked weeks 4-6
o May remove brace for supervised AAROM and home heel slides up to 15 degrees beyond the brace setting at each time point
o Cryotherapy
o Work on motion right away!
o Quadriceps re-education: quadriceps sets with towel roll under knee
• Sitting knee ROM exercise: AAROM KF, PROM KE
• Quad set with towel roll under knee
• Hip progressive resisted exercises: pain-free SLR with brace if lag is present
• Distal strengthening (PF)
• Flexibility exercises (hamstrings, gastrocnemius)

MINIMUM CRITERIA FOR ADVANCEMENT TO NEXT PHASE:
• Fair to good quadriceps contraction
• Good patellar mobility in medial direction
• ROM: 0° knee extension to ≥90° knee flexion
• 0/10 pain at rest
• Able to SLR pain-free without quadriceps lag

PHASE II: GAIT PHASE (WEEKS 7-10)

GOALS:
• Independence in HEP, as instructed
• Control pain, inflammation, effusion
• Promote healing
• ROM 0° KE-110° KF (8 weeks), 120° (10 weeks) to full ROM
• Good patella mobility
• Good quad contraction
• Normalize gait
• Postural stability, alignment and N-M control in single limb stance
• 0/10 pain with ADLs, therapeutic exercise: Recognize pain-free arc of motion

PRECAUTIONS:
• Sign and symptom provocation: pain, inflammation, quadriceps shut down, joint effusion
• Concomitant procedures: TTT, articular cartilage procedure
• Lateralization of the patella
• Pathological gait pattern (quadriceps avoidance; bent knee)
• Arc of motion during exercise

TREATMENTRECOMMENDATIONS:
• HEP: advance as tolerated. Continue phase I exercises, as appropriate
• Patient education: Activity modification, progression of gait training, cryotherapy
• Patellar mobilization, MD directed
• ROM exercises:
o Sitting PROM to AAROM KE in a pain-free arc of motion (no cartilage injury) to AAROM KF
o KF: sitting progressing to stair ROM, supine wall ROM as tolerated(~125°KF in sitting, quad control)

• Gait training: heel toe gait pattern [with adequate quad control (SLR without a lag, ability to achieve terminal knee extension) and knee ROM] to ensure normal loading response; hydro–treadmill (adequate wound healing) or anti-gravity treadmill. Low grade elevation or retro-walking to encourage N-M control with KF during loading response
• Quadriceps strengthening: progress pain-free arc of motion, close chain preferred
o Quad sets, submaximal multi angle isometrics, Estim, biofeedback, as needed
o Leg press: monitor arc of motion (bilateral, eccentric)
o Initiate forward step up (FSU) progression, 6” step with adequate strength
• Bicycle: progressing from short crank to standard crank as ROM allows (115° KF in sitting), 80 RPMs
• Flexibility exercises – evaluation-based: AROM KF with hip extension in standing
• Advance proximal strength and core training: (i.e. hip extension with knee flexion, side planks, bridge)
• Hydrotherapy for gait, single limb alignment and stability, proximal strengthening
• Initiate balance and proprioceptive training: double limb support on progressively challenging surfaces to single limb support on level surface only with demonstration of good alignment, stability and N-M control

MINIMUM CRITERIA FOR ADVANCEMENT:
• ROM 0° KE–> 115° KF
• Normal gait pattern
• Good patella mobility
• Postural stability, alignment and N-M control in single limb stance
• 0/10 pain with ADLs and therapeutic exercise
• Independent HEP

PHASE III: STRENGTHENING (WEEKS 11-18+)

GOALS:
• Independent HEP
• Control pain, effusion and inflammation
• 0/10 pain with ADLs, therapeutic exercise
• ROM: WNLs, 130° (12 weeks)
• Normalize gait on level surfaces and stairs
• Address imbalances
• Good single limb dynamic balance
• Eccentric quadriceps and pelvic control with 6”/ 8” FSD
• Initiate running program, plyometrics (bilateral)
• Symmetry, quality, alignment during selected movement patterns: squat, jump in place

PRECAUTIONS:
• Sign and symptom provocation: pain, and active inflammation/ effusion, quadriceps shutdown
• Gait deviations
• “Too much, too soon” progression

TREATMENT RECOMMENDATIONS:
• HEP, as instructed
• Educate patient: Activity modification, individualized, and cryotherapy
• Quadriceps strengthening: progress as tolerated, monitor arc of motion, closed chain preferred
o FSU progression: 6” step progressing to 8” step (dependent on patient height)
o Eccentric leg press progressing to:
o Forward step down (FSD) progression: 6” step progressing to 8” step (dependent on patient height)
o Squat progression: chair squats, (use ball if necessary), to free squats
• ROM exercises:
o (AA) ROM KE (monitor motion) to AAROM KF in sitting to supine wall slides to stair stretch
• Gait training to emphasize heel-toe gait pattern with emphasis on loading response
• Advance proximal strength through functional activities (bridging progression, hip extension with KF, clock, RDL, windmill, lawn mower) and core training (planks, side planks, Sahrmann progression)
• Balance progression with postural alignment and N-M control (static to dynamic, introduce different planes of motion, challenging surfaces)
• Address muscle imbalances –evaluation-based: (i.e. 2 joint hip flexor length)
• Cross training: elliptical trainer initiated with good strength/ quality during 6” FSU, bicycle (80 RPMs), swimming (crawl, back stroke)
• Initiate running program (late phase): with eccentric quadriceps control during 8” FSD and MD clearance
o 30 second interval initially
• Initiate plyometric program with MD clearance and evidence of good eccentric quadriceps control
o Vertical jumping progression: Jump up to jump in place

CRITERIA FORADVANCEMENT:
• No pain or swelling, normal ROM
• Normalize gait
• Ability to demonstrate alignment, control, stability in single limb stance during dynamic activities
• Core stability: Single leg bridge = 30 s, Sahrmann ≥ level 3
• Able to ascend 6”/ 8” step with good control
• Able to descend 6”/ 8” step with good control, and alignment
• Symmetry, quality, alignment during selected movement patterns
• Independence in a home exercise program

PHASE IV: ADVANCED STRENGTHENING AND FUNCTION (WEEKS 19-24)

GOALS:
• Lack of pain, apprehension with sport specific movements
• Maximize strength and flexibility as to meet demands of individual’s sport activity
• Ability to demonstrate strategy, symmetry, quality, control and alignment during selected movement patterns: squat, jump (vertical and horizontal), single leg squat
• Isokinetic test: 180° / sec and 300°/ sec 85% limb symmetry index (LSI)
• Cardiovascular fitness to meet demands of sport

PRECAUTIONS:
• Pain with therapeutic exercise & functional activities
• Inadequate strength, functional strength, ROM, flexibility, fitness when returning to sport

TREATMENT RECOMMENDATIONS:
• Continue to advance LE strengthening, flexibility, dynamic single limb stability & agility programs
• Continue to address muscle imbalances – evaluation-based
• Advance core stability
• Cross training
• Advance plyometric program with MD clearance and evidence of good eccentric quadriceps control
o Vertical jumping progression: Jump down
o Horizontal jumping progression: Broad jump, single leg landings
o Progress running program
o Cutting, deceleration, change of direction with MD clearance and dynamic single limb stability

CRITERIA FOR DISCHARGE/RETURN TO SPORT:
• Isokinetic test at 180°/ sec and 300°/ sec: 85% limb symmetry index (LSI)
• Demonstrate symmetry, quality, alignment during selected movement patterns
• Medical clearance by surgeon for return to play progression
• Lack of apprehension with sport specific movements
• Hop Test > 85% limb symmetry
• Demonstrate quality of movement with required sports specific activities