Introduction
- Diego Herrera, MD
- Najeeb Khan, MD
- Donald C. Fithian, MD
- Christopher M. Powers, PhD, PT
- Najeeb Khan, MD
Epidemiology
- •
The average annual incidence of primary patellar dislocation is 5.8 per 100,000. This incidence increases to 29 per 100,000 in the 10- to 17-year-old age group. The majority of these patients will experience no further instability with reported recurrence rates of 15% to 44% after conservative treatment.
- •
Although recurrence is the exception and not the rule, many patients continue to be symptomatic following their dislocation episode. At 6 months postinjury, 58% of patients continue to have limitations with strenuous activity. Failure to return to sports has been reported in up to 55% of patients.
- •
There is a slight female predilection.
Pathophysiology
Intrinsic Factors
- •
The medial patellofemoral ligament (MPFL) is the primary ligamentous restraint against lateral patellar displacement. In early flexion, the medial retinacular structures (particularly the MPFL) provide the primary restraint to lateral displacement of the patella. As the patella engages the trochlear groove with increasing flexion, trochlear geometry provides increasing constraint to mediolateral patellar motion.
- •
Deficiency of constraint by the MPFL can be exacerbated by patella alta, which causes the patella to engage late within the trochlea so that the patella spends a greater proportion of early flexion in a precarious state where only the ligaments constrain its mediolateral motion.
- •
A lateralized tibial tubercle, as measured by tibial-tubercle-trochlear groove (TT-TG) distance on CT or MRI, is associated with patellar instability.
- •
Systemic hypermobility can increase the risk of patellar instability, and articular injury is less likely in this cohort.
Extrinsic Factors
- •
A history of contralateral patellar dislocation would increase the risk of recurrence sixfold, as much as a previous dislocation, even on the index knee.
Traumatic Factors
- •
The most common mechanisms of patellar dislocation are sports (61%) and dance (9%) injuries.
- •
The mechanism of injury is most often with the foot planted and internal rotation of the femur, with subsequent tibia external rotation relative to the femur.
- •
Direct trauma causing patellar translation and ultimately dislocation is also seen.
Classic Pathological Findings
- •
Injury to the MPFL is a lesion of necessity. Residual laxity of the ligament is primarily responsible for patellar instability after the initial dislocation event. Injury to the MPFL may occur at more than one location along its length during the dislocation.
- •
Articular cartilage injuries have been reported in up to 95% of first-time patellar dislocations, although most do not require surgery.
- •
Imaging studies may also show trochlear dysplasia, patella alta, increased TT-TG distance, and patellar tilt.
Clinical Presentation
History
- •
For the acute first-time dislocation, knee swelling, and hemarthrosis are nearly always seen. Symptoms associated with the swelling and hemarthrosis, such as pain, decreased range of motion (ROM), and gait changes, can be seen.
- •
For recurrent dislocators, minimal pain and swelling is seen between episodes of patellar instability. These patients may complain of their knee giving way unexpectedly during activities of daily living and/or sports.
- •
It is crucial that the clinician distinguish the patient who has true episodic patellar instability from those who primarily complain of pain.
Physical Examination
Abnormal Findings
- •
For first-time dislocators, a large effusion with tenderness to palpation about the medial retinaculum is a typical finding. If the effusion is large and tense, aspiration can serve as a palliative measure and hasten normalization of ROM and gait.
- •
Apprehension to lateral patella translation, usually accompanied by pain with straight leg raise and active ROM.
- •
The Q-angle is rarely helpful, as it is imprecise and changes with patellar mobility. If a patella is subluxed laterally, the Q-angle measurement is falsely low. However, femoral and tibial torsion can play a role in patellar instability, with the largest lateral force placed on the patella when the tibia rotates externally in terminal knee extension. A distance between the tibial tuberosity and the trochlear groove (TT-TG as measured on axial imaging) that exceeds 20 mm is nearly always associated with patellar instability.
Imaging
- •
Anteroposterior (AP), lateral, and merchant radiographs are used to confirm patellar location, presence of osteochondral fracture, and patellofemoral relationships.
- •
The lateral view with the knee flexed 30 degrees can help determine patella height. The Caton-Deschamps ratio is the distance between the lower edge of the patellar joint surface to the upper edge of the tibial plateau divided by the length of the patellar articular surface. A ratio greater than 1.2 signifies patella alta ( Figure 28-1 ).
FIGURE 28-1
A, Patellar height. The height of the patella is surprisingly difficult to measure reliably. The Caton-Deschamps ratio is the distance between the lower edge of the patellar joint surface and the upper edge of the tibial plateau (AT) and the length of the patellar articular surface (AP). B, Severe patella alta.
- •
The lateral view with the posterior condyles aligned can evaluate trochlear dysplasia. The “crossing” sign, where the curve of the trochlear floor crosses the anterior contour of the lateral femoral condyle, represents flattening of the trochlear groove and absence of trochlear constraint against patellar displacement. Trochlear prominence (also called a trochlear “boss,” “bump,” or “eminence”) is represented by the distance between the most anterior point of the trochlear floor and a line drawn along the distal 10 cm of the anterior femoral cortex. The degree of trochlear prominence on a lateral radiograph correlates with the severity of dysplasia ( Figure 28-2 ).
FIGURE 28-2
Crossing sign. A, Normal trochlea. On the lateral view, the profile shows a sclerotic curved white line that corresponds to the floor of the trochlea (+). The curves representing the trochlear ridges ( arrows ) do not cross the curve of the trochlear floor. Note that accurate interpretation of the lateral view requires that the posterior condyles be aligned. B, The crossing sign is a simple and characteristic image, a qualitative criterion of trochlear dysplasia. The arrowhead indicates the point where the curve of the trochlear floor crosses the anterior contour of the lateral femoral condyle. By definition, the trochlea is flat at this level. This sign is of fundamental importance in the diagnosis. C, The prominence ( bump ) is a quantitative characteristic that is particularly significant in trochlear dysplasia. The prominence represents the distance between the most anterior point of the trochlear floor ( dashed line ) and a line drawn along the distal 10 cm of the anterior femoral cortex ( solid line ). The greater the trochlear prominence, the greater the dysplasia.
- •
MRI examination for first-time dislocators, particularly if a hemarthrosis is present, should be considered to assess for osteochondral or chondral injuries that are amenable to surgical intervention.
- •
Axial MRI images are also used to determine TT-TG offset ( Figure 28-3 ).
FIGURE 28-3
TT-TG offset. A, The lateral offset of the tibial tubercle is suspected clinically, but the analysis is qualitative. A CT scan (or an MRI) allows a reliable and reproducible measurement. B, Two axial cuts ( slices ) are superimposed: one through the apex of the tibial tubercle (TT) and the other through the femur at the level where the notch posteriorly resembles a curved “Roman arch” ( arrow ) (trochlear groove [TG]). The TT-TG offset is the distance between the most anterior point of the TT and the apex of the TG along a line parallel to the posterior condylar line ( dashed line ).
Differential Diagnosis
- •
For a primary complaint of instability, it is important to evaluate the cruciates, collaterals, and menisci, as injuries to these structures can accompany patellar dislocations.
- •
Complaints of anterior knee pain carry a long differential diagnosis, including tumors, Hoffa disease, Osgood Schlatter disease, osteochondritis dessicans, stress fracture, patellofemoral osteoarthritis, bursitis, Sinding-Larson-Johanssen syndrome, symptomatic bipartite patella, meniscal pathology, loose bodies, and others.
Treatment
Nonoperative Management
- •
Acute first-time patellar dislocations are treated with reduction and measures such as cryotherapy and NSAIDS to reduce pain and swelling. Tense hemarthrosis should be aspirated. Weight bearing as tolerated is encouraged, often with a knee immobilizer if symptoms do not allow sufficient quadriceps control. Physical therapy is started to address pain and swelling, ROM, normalization of gait, and ultimately quadriceps strengthening and proximal lower limb control.
- •
There is no established standard of care regarding immobilization after first-time dislocation. Whereas a simple knee sleeve was associated with relatively higher rates of recurrent dislocation, strict immobilization can cause muscular atrophy, weakness, and stiffness.
Surgical Indications
- •
An osteochondral fracture that is visible on conventional radiographs is likely to be a significant lesion that should be followed by an MRI and possible surgical excision or fixation.
- •
MPFL reconstruction is best used to treat episodic lateral patellar instability due to excessive laxity of medial retinacular patellar stabilizers. The ideal candidate has minimal pain between episodes of patellar instability and seeks medical care primarily to address the occasional dislocation or subluxation. A tibial tubercle osteotomy in addition to MPFL reconstruction is considered in patients with TT-TG > 20 mm, patella alta, or both.
Evidence
Multiple-Choice Questions
- QUESTION 1.
The primary ligamentous restraint against lateral patellar displacement is the:
- A.
Medial collateral ligament (MCL)
- B.
Medial patellomeniscal ligament (MPML)
- C.
Medial patellofemoral ligament (MPFL)
- D.
Trochlea
- A.
- QUESTION 2.
The most common mechanisms of patellar dislocation are:
- A.
Direct trauma
- B.
Motor vehicle collisions
- C.
Sports and dance
- D.
Ehlers-Danlos syndrome
- A.
- QUESTION 3.
How do you measure excessive lateralization of the tibial tubercle?
- A.
Merchant view
- B.
Lateral view with the knee flexed 30 degrees
- C.
Axial imaging; measure tibial tubercle to trochlear groove offset (TT-TG)
- D.
Q-angle
- A.
- QUESTION 4.
Articular cartilage injuries are seen in up to _____% of first-time patellar dislocators.
- A.
0%
- B.
20%
- C.
95%
- D.
100%
- A.
- QUESTION 5.
Choose the best indication for MPFL reconstruction:
- A.
Patellofemoral pain syndrome
- B.
First-time patellar dislocation with tense effusion
- C.
Episodic patellar instability with minimal pain between episodes
- D.
Patellofemoral osteoarthritis
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology: Intrinsic Factors )
- QUESTION 2.
Correct answer: C (see Pathophysiology: Traumatic Factors )
- QUESTION 3.
Correct answer: C (see Pathophysiology: Intrinsic Factors )
- QUESTION 4.
Correct answer: C (see Classic Pathologic: Intrinsic Factors)
- QUESTION 5.
Correct answer: C (see Surgical Indications )
Nonoperative Rehabilitation of Patellar Instability
- Najeeb Khan, MD
- Donald C. Fithian, MD
- Christopher M. Powers, PhD, PT
- Donald C. Fithian, MD
- •
Most patients who suffer a first-time patellar dislocation do not have a recurrence. More than half, however, have some limitations with strenuous activities and do not return to sports. The treatment goals after a first-time dislocation are to reduce the patella, diminish pain and swelling, normalize gait patterns, avoid recurrence, return to activities of daily living, and, ultimately, return to sports.
- •
Patients who have failed nonoperative treatment are considered for surgical intervention. The results of operative treatment, namely, MPFL repair, after primary patellar dislocations generally are not different from nonoperative treatment, although some authors report decreased recurrence with MPFL repair. Controversy persists regarding operative treatment of the first-time patellar dislocator. The standard of care at this time is a trial of nonoperative treatment.
- •
Younger patients and those with predisposing anatomic factors, such as patella alta, trochlear dysplasia, and a high TT-TG offset, may have a higher risk of recurrence and failure of nonoperative treatment.
- •
Patients with patellofemoral pain, particularly females, may have decreased hip muscular strength in abduction, external rotation, and extension. Once pain and swelling are treated, the ultimate goal is to gain proximal limb control and avoid valgus collapse and dynamic hip internal rotation that comes with weak hip abductors and external rotators.
- •
Patellofemoral rehabilitation, both for nonoperative and operative treatment of patellar instability, should ultimately address dynamic lower extremity function ( Figure 28-4 ).
FIGURE 28-4
Schematic of the various potential contributions of limb malalignment and malrotation to increase the dynamic Q-angle: A, Hip adduction. B, Femoral internal rotation. C, Genu valgum. D, Tibial external rotation. E, Foot pronation.
- •
The rehabilitation protocol, following, is somewhat arbitrarily divided into phases. Patients with underlying patellofemoral pathoanatomy (e.g., trochlear dysplasia, patella alta) may achieve goals and progress slower than those without. Athletes who have sustained a patella dislocation caused by direct trauma are generally expected to progress well with therapy, as they may not necessarily have the degree of proximal weakness and imbalance as their counterparts who dislocated caused by indirect trauma. Progression to the next stage is contingent upon achieving the goals of the prior stage.
- •
Reduce pain and swelling
- •
Normalize ROM
- •
Normalize gait pattern
- •
Quadriceps strengthening
- •
Proximal lower limb control training
Phase I (weeks 0 to 2)
Goals
- •
The goals of this phase are to reduce pain and swelling, initiate muscular strength and endurance training without pain, and introduce balance training.
Protection
- •
Encourage weight bearing as tolerated in a hinged knee brace, locked in extension for ambulation. The knee brace is unlocked once appropriate quad strength and control are achieved.
- •
Crutches may be provided initially, with encouragement to wean from supportive devices as soon as possible.
Management of Pain and Swelling
- •
Pain and swelling reduction techniques: rest, cryotherapy, NSAIDs.
- •
Modalities such as E-stim and biofeedback can be used as needed.
Therapeutic Exercises
- •
Gentle quadriceps strengthening should begin as soon as pain allows. Care should be taken to avoid active terminal knee extension, as this range of motion places high stress on the patellofemoral joint. In this early phase, patients also should perform nonweightbearing exercises targeting the hip abductors, external rotators, and extensors. When performing strengthening exercises for the gluteus medius, the patient must take care to minimize the contribution of the tensor fascia lata, as contraction of this muscle contributes to medial rotation of the lower extremity.
- •
Balance training is introduced as symptoms allow including wobble board, BOSU ball, single-leg squat and reach, and other methods.
Open and Closed Kinetic Chain Exercises
- •
Care must be taken to avoid open chain active terminal knee extension (15° to full extension), as the stress on the patellofemoral is quite high in this range.
Phase II (weeks 3 to 6)
Goals
- •
The goals of this phase are to fully treat pain and swelling, enhance leg strength and proximal limb control, normalize gait, and prepare for return to functional activities.
Protection
- •
Knee brace should be unlocked by Phase II and then exchanged for a neoprene sleeve.
Management of Pain and Swelling
- •
Treatment of pain and swelling continues with cryotherapy and NSAIDs as needed.
Therapeutic Exercises
- •
Facilitation of normal gait is an essential component of the overall treatment plan. This is particularly important for the returning athlete (especially runners) in whom even a slight gait deviation can be compounded by repetitive loading. The clinician should pay particular attention to the quadriceps avoidance gait pattern (walking with the knee extended or hyper-extended). Because knee flexion during weight acceptance is critical for shock absorption, this key function must be restored to prevent the deleterious effects of high-impact tibiofemoral joint loading.
- •
Strength training as in Phase I continues. Once the patient can isolate the proximal muscles of interest in nonweightbearing, progression to weightbearing activities can begin.
- •
The concept of neutral lower extremity alignment is introduced. This involves alignment of the lower extremity such that the anterior superior iliac spine (ASIS) and knee remain positioned over the second toe, with the hip positioned in neutral. Postural alignment and symmetrical strengthening should be emphasized during all exercises.
- •
If the patient has a difficult time maintaining proper lower extremity alignment during initial weightbearing exercises, femoral strapping can be used to provide kinesthetic feedback and to augment muscular control and proprioception. Also, taping or bracing of the patellofemoral joint may be used if pain is limiting the patient’s ability to engage in a meaningful weightbearing exercise program. Partial squats, which may have started already in very controlled environment with supervision, can be advanced to incorporate a BOSU ball or similar device to facilitate proximal control. Close supervision is required to ensure proper execution, as most patients may exhibit abnormal postures or movements during these tasks. Once the patient understands the proper movement and goal of the task, continued performance in front of a mirror provides useful feedback.
- •
As strength, control, and balance progress, single-leg activities may be initiated. This is the final step before returning to full unrestricted activity.
Phase III (weeks 7 and beyond)
- •
Rehabilitation from this point onward requires careful assessment and progressive development of proximal lower limb control.
- •
Patients should be encouraged to return to their sport or activity gradually once they can achieve satisfactory single-limb dynamic control. With competitive or recreational athletes who will be returning to full participation, plyometric training (e.g., jump training) should be considered during this phase of the rehabilitation program. As patients, particularly athletes, return to sport activities, repetitive forces applied through the knee joint must be controlled adequately to allow continued healing of the injured or repaired tissues.
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Surgical management is considered if patellar instability becomes recurrent and interferes with sports and/or activities of daily living.
Specific Criteria for Return to Sports Participation
- •
Full and painless ROM
- •
Absence of effusion and swelling
- •
Satisfactory and symmetric proximal single-limb dynamic control during high-impact activities (e.g., landing from a jump, cutting, etc.)
- •
Quadriceps, hamstring, and hip strength in at least 90% of the uninjured leg
- •
Psychologically ready to return to sports
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which of the following is not a treatment goal after first-time patellar dislocation?
- A.
Reduce pain and swelling
- B.
Normalize gait pattern
- C.
Surgical repair of the medial patellofemoral ligament
- D.
Return to activities of daily living
- A.
- QUESTION 2.
When are crutches discontinued after primary patellar dislocation?
- A.
After Phase I
- B.
After normalization of ROM
- C.
As soon as possible
- D.
Never
- A.
- QUESTION 3.
Activation of which muscle groups should be avoided?
- A.
Hip abductors and external rotators
- B.
Quadriceps and hamstrings
- C.
Vastus medialis oblique (VMO) and tensor fascia lata
- D.
Hip extensors
- A.
- QUESTION 4.
Surgical management is considered for:
- A.
Pain and swelling
- B.
Damage to the MPFL
- C.
Recurrence of patellar instability
- D.
Quicker return to sports
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Introduction )
- QUESTION 2.
Correct answer: C (see Phase I: Protection )
- QUESTION 3.
Correct answer: C (see Phase I: Therapeutic Exercises )
- QUESTION 4.
Correct answer: C (see Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention )
Postoperative Rehabilitation After Proximal Realignment Procedures and Medial Patellofemoral Ligament (MPFL) Reconstruction
- Kentaro Suzuki, MD
- Matthew Pifer, MD
- Najeeb Khan, MD
- Donald Fithian, MD
- Christopher M. Powers, PhD, PT
- Matthew Pifer, MD
Indications for Surgical Treatment
- •
Medial patellofemoral ligament (MPFL) reconstruction is best used to treat episodic lateral patella instability because of excessive laxity of medial retinacular stabilizers.
- •
The ideal candidate has minimal pain between episodes of patella instability and seeks medical care primarily to address the occasional dislocation or subluxation.
- •
It is imperative that the surgeon document MPFL laxity by physical examination, stress radiography, and/or arthrometry before committing to an MPFL reconstruction. Frequently, an examination under anesthesia is necessary to confirm laxity of the medial retinacular structures because of patient apprehension and discomfort in the clinic.
Brief Summary of Surgical Technique
Major Surgical Steps
- •
Examination under anesthesia includes an assessment of patella mobility. The diagnosis of patella instability requires that there be a soft or no end point to lateral patella displacement either at full extension or 30° flexion and that the patella be mobile enough during examination under anesthesia to displace it out of the trochlea with the knee at 30° flexion. A diagnostic arthroscopy may be done to diagnose and treat any chondral lesions on the lateral condyle and patella.
- •
A 3 cm vertical incision is made over the pes anserinus, and a semitendinosis hamstring autograft is harvested. Alternatively, an allograft tendon can be used. A longitudinal incision is made over the medial patella, and the medial patella is exposed subperiosteally. A long curved clamp is then used to develop the interval between the retinaculum and the capsule all the way to the medial femoral epicondyle such that the graft will ultimately lie between the capsular layer and the native MPFL.
- •
A 4.5 mm drill is used to create two right-angle tunnels in the proximal two-thirds of the patella. A short incision is made over the medial epicondyle, and a blind socket is drilled between the femoral epicondyle and adductor tubercle. Fluoroscopy and intraoperative isometry testing is used to confirm appropriate positioning of the femoral socket.
- •
The hamstring graft is fixated at the femur, passed deep to the retinacular layer toward the medial patella, and then passed through the patellar tunnels. With the patella centered in the trochlear groove at 30° knee flexion, there is neither slack nor tension in the graft. Each free end of the graft is doubled over and sutured to itself. Excessive medial constraint should be avoided, as overtightening the graft results in increased medial facet compression.
Details and Choices That May Affect Rehabilitation
Surgical
- •
Postoperative pain can interfere with active quadriceps contraction. Pain can also impede progress with range of motion (ROM). Operating at or near the medial epicondyle of the knee is often associated with postoperative stiffness because of the higher degrees of motion of the injured soft tissues relative to the femur during knee flexion and extension. It is important to address ROM aggressively in the early postoperative phase to avoid stiffness. Once motion has been established, medial pain and knee stiffness as a result of scarring at the femoral attachment of the graft is rarely a problem.
- •
Swelling, either as free intraarticular fluid (effusion) or as soft tissue edema, can interfere with ROM. In addition, effusion inhibits quadriceps function and may be harmful to articular cartilage.
- •
If autograft hamstring is harvested and used, avoid excessive hamstring stretching and strengthening for the first 6 weeks.
Anesthesia
- •
If regional anesthesia is used, await return of full motor function before starting weightbearing exercises.
Before Surgery: Overview of Goals, Milestones, and Guidelines
- •
The principles of rehabilitation after MPFL reconstruction are similar to those guiding rehabilitation following other ligamentous reconstructions of the knee, such as anterior cruciate ligament (ACL).
- •
Despite differences between MPFL and ACL reconstruction surgery, there are enough similarities in postoperative neuromuscular deficiencies to suggest that strategies found to be successful after ACL reconstruction should be considered for those who have undergone MPFL reconstruction.
- •
The keys are to address pain, ROM, quadriceps strengthening, and proximal lower limb control.
- •
Return of full ROM, pain control, and protected weightbearing are stressed in the early phases of recovery.
- •
Progression of strength training and return to functional activities follows lines of evidence regarding graft necrosis, remodeling, and tunnel ingrowth, which are most commonly associated with ACL reconstruction.
- •
It is important to have a thorough preoperative discussion with the patient regarding the potential risks, benefits, goals, and postoperative rehabilitation. The patient should have realistic expectations regarding postoperative pain and the need for active participation in healing, rehabilitation, and return to sports. Passively receiving surgery and then awaiting a desired result can lead to failure of the graft and delay (if not preclude) a return to the activities of daily living and sports.
- •
Return to sedentary work is usually possible 5 to 7 days after surgery once pain is controlled and narcotic usage is minimal. Family and/or friends should also be recruited to help during the postoperative period. Driving can be considered once off narcotics, weightbearing is comfortable, and distal neuromuscular control allows for normalized reaction time. This can take up to 6 weeks.
Phase I: Immediate Postoperative Period (days first 14)
Goals
- •
Pain control
- •
Reduce swelling and effusion
- •
Normalize ROM
- •
Return of quadriceps activation
- •
If regional anesthesia is used, await return of motor function before starting weightbearing exercises.
- •
Use leg elevation, circumferential wrap, and cryotherapy to reduce swelling and effusion.
- •
Early ROM is critical to reduce stiffness.
- •
Avoid hamstring stretches (if autograft is selected).
| PHASE I (weeks 0 to 4) | PHASE II (weeks 4 to 6) | PHASE III (weeks 6 to 10) | PHASE IV (weeks 10 to 14) | PHASE V (weeks 14 to 24) |
|---|---|---|---|---|
|
|
|
|
|
Management of Pain and Swelling
- •
Pain and swelling need to be addressed immediately postoperatively and controlled over the long term. Strict elevation of the limb and limited activity in the first 1 to 2 days postoperatively allows the acute inflammatory phase to pass without further perturbation by overaggressive therapy. During that time, cryotherapy is helpful, whether in the form of ice packs or commercially available cold therapy units.
Details of the Following Treatments That Are Appropriate to the Phase of Rehabilitation
- •
The patient is allowed to bear weight as tolerated with crutches with a hinged knee brace locked in extension. Unlock the hinged knee brace at 2 to 3 weeks as quad strength and control returns. MPFL reconstruction is not affected by axial loading of the joint. For this reason, weightbearing is encouraged after surgery as long as axial rotation of the limb is not allowed. The limb should be in a brace during weightbearing activities for 4 to 6 weeks postoperatively or at least until limb control is sufficient to prevent falls and rotational stress on the knee. Early weightbearing should follow a gradual progression from full protection in a rigid brace locked at full extension to an unlocked brace with crutches. Gradual increase to full weightbearing should be permitted as quadriceps strength is restored.
- •
Immediate, controlled ROM is not detrimental to fixation or graft development in well-positioned and securely fixed MPFL grafts.
- •
An early goal of rehabilitation after MPFL reconstruction is to reestablish full knee extension. Unlike ACL reconstruction, return of passive knee extension does not guarantee full active extension. For that to occur, attention must be focused on quadriceps strengthening. Pain and swelling can be mitigated with electrical stimulation, cold therapy, and compression wraps. Passive patellar glides should be instituted as soon as tolerated to reestablish normal passive patellar mobility within the trochlear groove in all directions (superiorly, inferiorly, medially, and laterally).
- •
Early application of neuromuscular electrical stimulation in combination with volitional contraction is used to minimize strength loss after surgery.
- •
Treatment to enhance proximal control can be started preoperatively and then immediately after surgery. Postoperatively, patients should perform nonweightbearing exercises targeting the hip abductors, external rotators, and extensors. When performing strengthening exercises for the gluteus medius, the patient must take care to minimize the contribution of the tensor fascia lata, as contraction of this muscle contributes to medial rotation of the lower extremity. Once the patient can isolate the proximal muscles of interest in nonweightbearing, progression to weightbearing activities can begin.
Phase II: Postoperative (weeks 2 to 6)
Goals
- •
Normalize ROM
- •
Discontinue crutches
- •
Discontinue brace
Related posts:
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Midfoot Strains and Sprains and Lisfranc Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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