Luxacion Patelar PDF

EXTENSOR MECHANISM INJURIES
Chapter 28
Patellar Instability
INTRODUCTION
Diego Herrera, MD, Najeeb Khan, MD, Donald C. Fithian, MD, and Christopher M. Powers, PhD, PT
Epidemiology late within the trochlea so that the patella spends a

greater proportion of early flexion in a precarious state
• The average annual incidence of primary patellar dis- where only the ligaments constrain its mediolateral
location is 5.8 per 100,000. This incidence increases to motion.8,9
29 per 100,000 in the 10- to 17-year-old age group. • A lateralized tibial tubercle, as measured by tibial-
The majority of these patients will experience no tubercle-trochlear groove (TT-TG) distance on CT or
further instability with reported recurrence rates of MRI, is associated with patellar instability.10
15% to 44% after conservative treatment.1-3 • Systemic hypermobility can increase the risk of patellar
• Although recurrence is the exception and not the rule, instability, and articular injury is less likely in this
many patients continue to be symptomatic following cohort.11,12
their dislocation episode. At 6 months postinjury, 58%
of patients continue to have limitations with strenuous Extrinsic Factors
activity. Failure to return to sports has been reported
in up to 55% of patients.3 • A history of contralateral patellar dislocation would
• There is a slight female predilection.3,4 increase the risk of recurrence sixfold, as much as a
previous dislocation, even on the index knee.1
Pathophysiology Traumatic Factors

• The most common mechanisms of patellar dislocation
Intrinsic Factors
are sports (61%) and dance (9%) injuries.1
• The medial patellofemoral ligament (MPFL) is the • The mechanism of injury is most often with the foot
primary ligamentous restraint against lateral patellar planted and internal rotation of the femur, with subse-
displacement.5-7 In early flexion, the medial retinacular quent tibia external rotation relative to the femur.
structures (particularly the MPFL) provide the primary • Direct trauma causing patellar translation and ulti-
restraint to lateral displacement of the patella. As the mately dislocation is also seen.
patella engages the trochlear groove with increasing
flexion, trochlear geometry provides increasing con- Classic Pathological Findings
straint to mediolateral patellar motion.
• Deficiency of constraint by the MPFL can be exacer- • Injury to the MPFL is a lesion of necessity.13 Residual
bated by patella alta, which causes the patella to engage laxity of the ligament is primarily responsible for
927
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928 EXTENSOR MECHANISM INJURIES
patellar instability after the initial dislocation event. laterally, the Q-angle measurement is falsely low.
Injury to the MPFL may occur at more than one loca- However, femoral and tibial torsion can play a role in
tion along its length during the dislocation.14 patellar instability, with the largest lateral force placed
• Articular cartilage injuries have been reported in up to on the patella when the tibia rotates externally in ter-
95% of first-time patellar dislocations, although most minal knee extension. A distance between the tibial
do not require surgery.15 tuberosity and the trochlear groove (TT-TG as mea-
• Imaging studies may also show trochlear dysplasia, sured on axial imaging) that exceeds 20 mm is nearly
patella alta, increased TT-TG distance, and patellar always associated with patellar instability.10
tilt.10
Imaging
• Anteroposterior (AP), lateral, and merchant radio-
Clinical Presentation graphs are used to confirm patellar location, presence
of osteochondral fracture, and patellofemoral
History relationships.
• For the acute first-time dislocation, knee swelling, and • The lateral view with the knee flexed 30 degrees can
hemarthrosis are nearly always seen. Symptoms associ- help determine patella height. The Caton-Deschamps
ated with the swelling and hemarthrosis, such as pain, ratio is the distance between the lower edge of the
decreased range of motion (ROM), and gait changes, patellar joint surface to the upper edge of the tibial
can be seen. plateau divided by the length of the patellar articular
• For recurrent dislocators, minimal pain and swelling is surface. A ratio greater than 1.2 signifies patella alta
seen between episodes of patellar instability. These (Figure 28-1).
patients may complain of their knee giving way unex- • The lateral view with the posterior condyles aligned
pectedly during activities of daily living and/or sports. can evaluate trochlear dysplasia. The “crossing” sign,
• It is crucial that the clinician distinguish the patient where the curve of the trochlear floor crosses the ante-
who has true episodic patellar instability from those rior contour of the lateral femoral condyle, represents
who primarily complain of pain. flattening of the trochlear groove and absence of troch-
lear constraint against patellar displacement. Trochlear
Physical Examination prominence (also called a trochlear “boss,” “bump,”
or “eminence”) is represented by the distance between
Abnormal Findings the most anterior point of the trochlear floor and a line
• For first-time dislocators, a large effusion with tender- drawn along the distal 10 cm of the anterior femoral
ness to palpation about the medial retinaculum is a cortex. The degree of trochlear prominence on a lateral
typical finding. If the effusion is large and tense, aspira- radiograph correlates with the severity of dysplasia
tion can serve as a palliative measure and hasten nor- (Figure 28-2).
malization of ROM and gait. • MRI examination for first-time dislocators, particu-
• Apprehension to lateral patella translation, usually larly if a hemarthrosis is present, should be considered
accompanied by pain with straight leg raise and active to assess for osteochondral or chondral injuries that
ROM. are amenable to surgical intervention.
• The Q-angle is rarely helpful, as it is imprecise and • Axial MRI images are also used to determine TT-TG
changes with patellar mobility. If a patella is subluxed offset (Figure 28-3).
T
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
A B tibial plateau (AT) and the length of the patellar articular
surface (AP). B, Severe patella alta.
PATELLAR INSTABILITY 929
FIGURE 28-2. Crossing sign. A,

Normal trochlea. On the lateral view,
the profile shows a sclerotic curved A
white line that corresponds to the floor
of the trochlea (+). The curves repre-
senting 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 character-
istic 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 signifi-
cant in trochlear dysplasia. The promi-
nence 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. B C
• Complaints of anterior knee pain carry a long differen-

Differential Diagnosis tial diagnosis, including tumors, Hoffa disease, Osgood
• For a primary complaint of instability, it is important Schlatter disease, osteochondritis dessicans, stress frac-
to evaluate the cruciates, collaterals, and menisci, as ture, patellofemoral osteoarthritis, bursitis, Sinding-
injuries to these structures can accompany patellar Larson-Johanssen syndrome, symptomatic bipartite
dislocations. patella, meniscal pathology, loose bodies, and others.
TAGT G = 21 MM
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 2
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 con- A B
dylar line (dashed line).
Treatment This is a prospective cohort study that identifies risk factors

in 189 patients with acute patellar dislocations and a minimum
Nonoperative Management follow up of 2 years (range of 2 to 5 years). Patellar disloca-
• Acute first-time patellar dislocations are treated with tors with a previous history of patellar instability were more
likely to be females. These patients also have a higher risk to
reduction and measures such as cryotherapy and
have subsequent instability episodes than first-time disloca-
NSAIDS to reduce pain and swelling. Tense hemar tors. (Level I evidence)
throsis should be aspirated. Weight bearing as tolerated
is encouraged, often with a knee immobilizer if symp- Stefancin J, Parker R: First-time traumatic patellar dislocation:
toms do not allow sufficient quadriceps control. Physi- A systematic review. Clin Orthop Relat Res 455:93–101,
cal therapy is started to address pain and swelling, 2007.
ROM, normalization of gait, and ultimately quadri-
ceps strengthening and proximal lower limb control. In a systematic review of 70 Level I to IV studies that included
• There is no established standard of care regarding patients with first-time patella dislocation. The authors
immobilization after first-time dislocation. Whereas recommended initial nonoperative management except in
a simple knee sleeve was associated with relatively specific circumstances, including the presence of an osteo-
chondral fracture, substantial disruption of the medial patel-
higher rates of recurrent dislocation,16 strict immobili-
lar stabilizers, a laterally subluxated patella with normal
zation can cause muscular atrophy, weakness, and alignment of the contralateral knee, a second dislocation, or
stiffness. in patients not improving with appropriate rehabilitation.
(Level III evidence)
Surgical Indications
• An osteochondral fracture that is visible on conven-
tional radiographs is likely to be a significant lesion REFERENCES
that should be followed by an MRI and possible surgi- 1. Fithian DC, Paxton EW, Stone ML, et al: Epidemiology and natural
cal excision or fixation. history of acute patellar dislocation. Am J Sports Med 32:1114–
• MPFL reconstruction is best used to treat episodic 1121, 2004.
lateral patellar instability due to excessive laxity of 2. Hawkins RJ, Bell RH, Anisette G: Acute patellar dislocations. The
medial retinacular patellar stabilizers. The ideal candi- natural history. Am J Sports Med 14:117–120, 1986.
3. Atkin DM, Fithian DC, Marangi KS, et al: Characteristics of
date has minimal pain between episodes of patellar patients with primary acute lateral patellar dislocation and their
instability and seeks medical care primarily to address recovery within the first 6 months. Am J Sports Med 28:472–479,
the occasional dislocation or subluxation. A tibial 2000.
tubercle osteotomy in addition to MPFL reconstruction 4. Stefancin J, Parker R: First-time traumatic patellar dislocation:
A systematic review. Clin Orthop Relat Res 455:93–101,
is considered in patients with TT-TG > 20 mm, patella 2007.
alta, or both. 5. Hautamaa PV, Fithian DC, Kaufman KR, et al: Medial soft tissue
restraints in lateral patellar instability and repair. Clin Orthop
349:174–182, 1998.
6. Desio SM, Burks RT, Bachus KN: Soft tissue restraints to lateral
Evidence patellar translation in the human knee. Am J Sports Med 26:59–65,
1998.
7. Nomura E, Horiuchi Y, Kihara M: Medial patellofemoral ligament
Dejour H, Walch G, Nove-Josserand L, et al: Factors of patellar restraint in lateral patellar translation and reconstruction. Knee
instability: An anatomic radiographic study. Knee Surg Sports 7:121–127, 2000.
Traumatol Arthrosc 2:19–26, 1994. 8. Senavongse W, Amis AA: The effects of articular, retinacular, or
muscular deficiencies on patellofemoral joint stability. Bone Joint J
Case control study that identifies relevant radiographic and 87:577–582, 2005.
CT factors in knees with symptomatic patellar instability. The 9. Simmons E, Jr, Cameron JC: Patella alta and recurrent dislocation
following factors were common findings in the symptomatic of the patella. Clin Orthop 274:265–269, 1992.
knees: Trochlear dysplasia (85%), patellar tilt (83%), tibial 10. Dejour H, Walch G, Nove-Josserand L, et al: Factors of patellar
tuberosity-trochlear groove distance equal to or greater than instability: An anatomic radiographic study. Knee Surg Sports Trau-
20 mm (56%), patella alta (24%), and very rare findings in matol Arthrosc 2:19–26, 1994.
nonsymptomatic knees (3% to 6.5%). The identification of 11. Runow A: The dislocating patella: Etiology and prognosis in rela-
these factors can lead to treatments that correct the afore- tion to generalized joint laxity and anatomy of the patellar articula-
mentioned abnormalities. (Level IV evidence) tion. Acta Orthop Scand 201:1–53, 1983.
12. Stanitski CL: Articular hypermobility and chondral injury in
Desio SM, Burks RT, Bachus KN: Soft tissue restraints to lateral patients with acute patellar dislocation. Am J Sports Med 23:146–
150, 1995.
patellar translation in the human knee. Am J Sports Med 26:59– 13. Vainionpaa S, Laasonen E, Patiala H, et al: Acute dislocation of
65, 1998. the patella. Clinical, radiographic and operative findings in 64
In a biomechanical study that included nine cadaveric knees, consecutive cases. Acta Orthop Scand 57:331–333, 1986.
it was found that the medial patella femoral ligament was the 14. Sallay PI, Poggi J, Speer KP, et al: Acute dislocation of the patella.
A correlative pathoanatomic study. Am J Sports Med 24:52–60,
main restraint to lateral patellar translation at 20 degrees of 1996.
flexion, contributing 60% of the total restraining force. 15. Nomura E, Inoue M, Kurimura M: Chondral and osteochondral
(Level V evidence) injuries associated with acute patellar dislocation. Arthroscopy
19:717–721, 2003.
Fithian DC, Paxton EW, Stone ML, et al: Epidemiology and 16. Maenpaa H, Lehto MU: Patellar dislocation: The long-term results
natural history of acute patellar dislocation. Am J Sports Med of nonoperative management in 100 patients. Am J Sports Med
32:1114–1121, 2004. 25:213–217, 1997.
5. Choose the best indication for MPFL

Multiple-Choice Questions QUESTION
reconstruction:
QUESTION 1. The primary ligamentous restraint against A. Patellofemoral pain syndrome
lateral patellar displacement is the: B. First-time patellar dislocation with tense effusion
C. Episodic patellar instability with minimal pain
A. Medial collateral ligament (MCL)
between episodes
B. Medial patellomeniscal ligament (MPML)
D. Patellofemoral osteoarthritis
C. Medial patellofemoral ligament (MPFL)
D. Trochlea
QUESTION 2. The most common mechanisms of Answer Key
patellar dislocation are:
QUESTION 1. Correct answer: C (see Pathophysiology:
A. Direct trauma
Intrinsic Factors)
B. Motor vehicle collisions
C. Sports and dance QUESTION 2. Correct answer: C (see Pathophysiology:
D. Ehlers-Danlos syndrome Traumatic Factors)
QUESTION 3. How do you measure excessive lateraliza- QUESTION 3. Correct answer: C (see Pathophysiology:
tion of the tibial tubercle? Intrinsic Factors)
A. Merchant view
B. Lateral view with the knee flexed 30 degrees QUESTION 4. Correct answer: C (see Classic Pathologic:
C. Axial imaging; measure tibial tubercle to Intrinsic Factors)
trochlear groove offset (TT-TG) QUESTION 5. Correct answer: C (see Surgical
D. Q-angle Indications)
QUESTION 4. Articular cartilage injuries are seen in up
to _____% of first-time patellar dislocators.
A. 0%
B. 20%
C. 95%
D. 100%
NONOPERATIVE REHABILITATION OF PATELLAR INSTABILITY

Najeeb Khan, MD, Donald C. Fithian, MD, and Christopher M. Powers, PhD, PT
• Most patients who suffer a first-time patellar disloca- • Patients with patellofemoral pain, particularly females,
tion do not have a recurrence. More than half, however, may have decreased hip muscular strength in abduc-
have some limitations with strenuous activities and do tion, external rotation, and extension.4 Once pain and
not return to sports.1 The treatment goals after a first- swelling are treated, the ultimate goal is to gain proxi-
time dislocation are to reduce the patella, diminish pain mal limb control and avoid valgus collapse and dynamic
and swelling, normalize gait patterns, avoid recurrence, hip internal rotation that comes with weak hip abduc-
return to activities of daily living, and, ultimately, tors and external rotators.
return to sports. • Patellofemoral rehabilitation, both for nonoperative
• Patients who have failed nonoperative treatment are and operative treatment of patellar instability, should
considered for surgical intervention. The results of ultimately address dynamic lower extremity function
operative treatment, namely, MPFL repair, after (Figure 28-4).
primary patellar dislocations generally are not different • The rehabilitation protocol, following, is somewhat
from nonoperative treatment, although some authors arbitrarily divided into phases. Patients with underly-
report decreased recurrence with MPFL repair.2,3 Con- ing patellofemoral pathoanatomy (e.g., trochlear dys-
troversy persists regarding operative treatment of the plasia, patella alta) may achieve goals and progress
first-time patellar dislocator. The standard of care at slower than those without. Athletes who have sus-
this time is a trial of nonoperative treatment. tained a patella dislocation caused by direct trauma are
• Younger patients and those with predisposing ana- generally expected to progress well with therapy, as
tomic factors, such as patella alta, trochlear dysplasia, they may not necessarily have the degree of proximal
and a high TT-TG offset, may have a higher risk of weakness and imbalance as their counterparts who
recurrence and failure of nonoperative treatment. dislocated caused by indirect trauma. Progression to
• Modalities such as E-stim and biofeedback can be used

as needed.
Therapeutic Exercises
• Gentle quadriceps strengthening should begin as soon
1 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.5,6 In this early
phase, patients also should perform nonweightbearing
exercises targeting the hip abductors, external rotators,
2 and extensors. When performing strengthening exer-
cises for the gluteus medius, the patient must take care
3 to minimize the contribution of the tensor fascia lata,
as contraction of this muscle contributes to medial
4 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.
5 Open and Closed Kinetic Chain Exercises

• Care must be taken to avoid open chain active terminal
FIGURE 28-4. Schematic of the various potential contributions of limb
malalignment and malrotation to increase the dynamic Q-angle: A, knee extension (15° to full extension), as the stress on
Hip adduction. B, Femoral internal rotation. C, Genu valgum. D, Tibial the patellofemoral is quite high in this range.6
external rotation. E, Foot pronation.
the next stage is contingent upon achieving the goals

Phase II (weeks 3 to 6)
of the prior stage. Goals
GUIDING PRINCIPLES OF • The goals of this phase are to fully treat pain and swell-
ing, enhance leg strength and proximal limb control,
NONOPERATIVE REHABILITATION normalize gait, and prepare for return to functional
activities.
• Reduce pain and swelling
• Normalize ROM
• Normalize gait pattern Protection
• Quadriceps strengthening • Knee brace should be unlocked by Phase II and then
• Proximal lower limb control training exchanged for a neoprene sleeve.7
Phase I (weeks 0 to 2) Management of Pain and Swelling
Goals • Treatment of pain and swelling continues with cryo-

therapy and NSAIDs as needed.
• The goals of this phase are to reduce pain and swelling,
initiate muscular strength and endurance training Therapeutic Exercises
without pain, and introduce balance training.
• Facilitation of normal gait is an essential component
of the overall treatment plan. This is particularly
Protection
important for the returning athlete (especially runners)
• Encourage weight bearing as tolerated in a hinged knee in whom even a slight gait deviation can be com-
brace, locked in extension for ambulation. The knee pounded by repetitive loading. The clinician should
brace is unlocked once appropriate quad strength and pay particular attention to the quadriceps avoidance
control are achieved. gait pattern (walking with the knee extended or hyper-
• Crutches may be provided initially, with encourage- extended). Because knee flexion during weight accep-
ment to wean from supportive devices as soon as tance is critical for shock absorption,8 this key function
possible. must be restored to prevent the deleterious effects of
high-impact tibiofemoral joint loading.
• Strength training as in Phase I continues. Once the
Management of Pain and Swelling
patient can isolate the proximal muscles of interest in
• Pain and swelling reduction techniques: rest, cryother- nonweightbearing, progression to weightbearing activ-
apy, NSAIDs. ities can begin.
• The concept of neutral lower extremity alignment is • Satisfactory and symmetric proximal single-limb
introduced. This involves alignment of the lower dynamic control during high-impact activities (e.g.,
extremity such that the anterior superior iliac spine landing from a jump, cutting, etc.)
(ASIS) and knee remain positioned over the second toe, • Quadriceps, hamstring, and hip strength in at least
with the hip positioned in neutral. Postural alignment 90% of the uninjured leg
and symmetrical strengthening should be emphasized • Psychologically ready to return to sports
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 Evidence
kinesthetic feedback and to augment muscular control
and proprioception. Also, taping or bracing of the Atkin DM, Fithian DC, Marangi KS, et al: Characteristics of
patients with primary acute lateral patellar dislocation and their
patellofemoral joint may be used if pain is limiting the recovery within the first 6 months. Am J Sports Med 28:472–
patient’s ability to engage in a meaningful weightbear- 479, 2000.
ing exercise program. Partial squats, which may have
started already in very controlled environment with NEEDS ANNOTATION (Level III evidence)
supervision, can be advanced to incorporate a BOSU Camanho G, Viegas A, Bitar A, et al: Conservative versus surgi-
ball or similar device to facilitate proximal control. cal treatment for repair of the medial patellofemoral ligament
Close supervision is required to ensure proper execu- in acute dislocations of the patella. Arthroscopy 25:620–625,
tion, as most patients may exhibit abnormal postures 2009.
or movements during these tasks. Once the patient NEEDS ANNOTATION (Level II evidence)
understands the proper movement and goal of the task,
Christiansen SE, Jakobsen BW, Lund B, et al: Isolated repair of
continued performance in front of a mirror provides the medial patellofemoral ligament in primary dislocation of the
useful feedback. patella: a prospective randomized study. Arthroscopy 24:881–
• As strength, control, and balance progress, single-leg 887, 2008.
activities may be initiated. This is the final step before
NEEDS ANNOTATION (Level I evidence)
returning to full unrestricted activity.
Phase III (weeks 7 and beyond) REFERENCES

1. Atkin DM, Fithian DC, Marangi KS, et al: Characteristics of
• Rehabilitation from this point onward requires careful patients with primary acute lateral patellar dislocation and their
assessment and progressive development of proximal recovery within the first 6 months. Am J Sports Med 28:472–479,
lower limb control. 2000.
2. Christiansen SE, Jakobsen BW, Lund B, et al: Isolated repair of
• Patients should be encouraged to return to their sport the medial patellofemoral ligament in primary dislocation of the
or activity gradually once they can achieve satisfactory patella: a prospective randomized study. Arthroscopy 24:881–887,
single-limb dynamic control. With competitive or rec- 2008.
reational athletes who will be returning to full partici- 3. Camanho G, Viegas A, Bitar A, et al: Conservative versus surgical
pation, plyometric training (e.g., jump training) should treatment for repair of the medial patellofemoral ligament in acute
dislocations of the patella. Arthroscopy 25:620–625, 2009.
be considered during this phase of the rehabilitation 4. Prins MR, van der Wuff P: Females with patellofemoral pain syn-
program. As patients, particularly athletes, return to drome have weak hip muscles: a systematic review. Aust J Physiother
sport activities, repetitive forces applied through the 55:9–15, 2009.
knee joint must be controlled adequately to allow con- 5. Powers CM: The influence of altered lower-extremity kinematics on
patellofemoral joint dysfunction: a theoretical perspective. J Orthop
tinued healing of the injured or repaired tissues. Sports Phys Ther 33:647–660, 2003.
6. Steinkamp LA, Dillingham MF, Markel MD, et al: Biomechanical
considerations in patellofemoral joint rehabilitation. Am J Sports
Criteria for Abandoning Med 21:438–446, 1993.
7. Shellock FG, Mink JH, Deutsch AL, et al: Effect of a patellar realign-
Nonoperative Treatment and ment brace on patellofemoral relationships: evaluation with kine-
Proceeding to Surgery or More matic MR imaging. J Magn Reson Imag 4:590–594, 1994.
8. Perry J, Antonelli D, Ford W: Analysis of knee-joint forces during
Intensive Intervention flexed-knee stance. J Bone Joint Surg Am 57:961–967, 1975.
• Surgical management is considered if patellar instabil-

ity becomes recurrent and interferes with sports and/or
activities of daily living. Multiple-Choice Questions
QUESTION 1. Which of the following is not a treatment
goal after first-time patellar dislocation?
Specific Criteria for Return A. Reduce pain and swelling
to Sports Participation B. Normalize gait pattern
C. Surgical repair of the medial patellofemoral
• Full and painless ROM ligament
• Absence of effusion and swelling D. Return to activities of daily living
2. When are crutches discontinued after

QUESTION
primary patellar dislocation?
Answer Key
A. After Phase I QUESTION 1. Correct answer: C (see Introduction)
B. After normalization of ROM
C. As soon as possible QUESTION 2. Correct answer: C (see Phase I:
D. Never Protection)
QUESTION 3. Activation of which muscle groups should QUESTION 3. Correct answer: C (see Phase I: Therapeu-
be avoided? tic Exercises)
A. Hip abductors and external rotators QUESTION 4. Correct answer: C (see Criteria for Aban-
B. Quadriceps and hamstrings doning Nonoperative Treatment and Proceeding to
C. Vastus medialis oblique (VMO) and tensor fascia Surgery or More Intensive Intervention)
lata
D. Hip extensors
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
POSTOPERATIVE REHABILITATION AFTER PROXIMAL

REALIGNMENT PROCEDURES AND MEDIAL PATELLOFEMORAL
LIGAMENT (MPFL) RECONSTRUCTION
Kentaro Suzuki, MD, Matthew Pifer, MD, Najeeb Khan, MD, Donald Fithian, MD,
and Christopher M. Powers, PhD, PT
Indications for Surgical Treatment examination under anesthesia to displace it out of the
trochlea with the knee at 30° flexion. A diagnostic
• Medial patellofemoral ligament (MPFL) reconstruction arthroscopy may be done to diagnose and treat any
is best used to treat episodic lateral patella instability chondral lesions on the lateral condyle and patella.
because of excessive laxity of medial retinacular • A 3 cm vertical incision is made over the pes anserinus,
stabilizers. and a semitendinosis hamstring autograft is harvested.
• The ideal candidate has minimal pain between episodes Alternatively, an allograft tendon can be used. A lon-
of patella instability and seeks medical care primarily gitudinal incision is made over the medial patella, and
to address the occasional dislocation or subluxation. the medial patella is exposed subperiosteally. A long
• It is imperative that the surgeon document MPFL laxity curved clamp is then used to develop the interval
by physical examination,1 stress radiography,2 and/or between the retinaculum and the capsule all the way
arthrometry3 before committing to an MPFL recon- to the medial femoral epicondyle such that the graft
struction. Frequently, an examination under anesthesia will ultimately lie between the capsular layer and the
is necessary to confirm laxity of the medial retinacular native MPFL.
structures because of patient apprehension and discom- • A 4.5 mm drill is used to create two right-angle tunnels
fort in the clinic. in the proximal two-thirds of the patella. A short inci-
sion is made over the medial epicondyle, and a blind
socket is drilled between the femoral epicondyle and
adductor tubercle. Fluoroscopy and intraoperative
Brief Summary of Surgical Technique isometry testing is used to confirm appropriate posi-
tioning of the femoral socket.
Major Surgical Steps
• The hamstring graft is fixated at the femur, passed deep
• Examination under anesthesia includes an assessment to the retinacular layer toward the medial patella, and
of patella mobility. The diagnosis of patella instability then passed through the patellar tunnels. With the
requires that there be a soft or no end point to lateral patella centered in the trochlear groove at 30° knee
patella displacement either at full extension or 30° flexion, there is neither slack nor tension in the graft.
flexion and that the patella be mobile enough during Each free end of the graft is doubled over and sutured
to itself. Excessive medial constraint should be

avoided,4-6 as overtightening the graft results in which are most commonly associated with ACL
increased medial facet compression. reconstruction.
• It is important to have a thorough preoperative
discussion with the patient regarding the potential
risks, benefits, goals, and postoperative rehabilita-
Details and Choices That May tion. The patient should have realistic expectations
Affect Rehabilitation regarding postoperative pain and the need for
active participation in healing, rehabilitation, and
Surgical return to sports. Passively receiving surgery and
• Postoperative pain can interfere with active quadriceps then awaiting a desired result can lead to failure of
contraction. Pain can also impede progress with range the graft and delay (if not preclude) a return to the
of motion (ROM). Operating at or near the medial activities of daily living and sports.
epicondyle of the knee is often associated with postop- • Return to sedentary work is usually possible 5 to 7
erative stiffness because of the higher degrees of motion days after surgery once pain is controlled and
of the injured soft tissues relative to the femur during narcotic usage is minimal. Family and/or friends
knee flexion and extension. It is important to address should also be recruited to help during the postop-
ROM aggressively in the early postoperative phase to erative period. Driving can be considered once off
avoid stiffness. Once motion has been established, narcotics, weightbearing is comfortable, and distal
medial pain and knee stiffness as a result of scarring at neuromuscular control allows for normalized
the femoral attachment of the graft is rarely a problem. reaction time.8 This can take up to 6 weeks.
• Swelling, either as free intraarticular fluid (effusion) or
as soft tissue edema, can interfere with ROM. In addi-
tion, effusion inhibits quadriceps function7 and may be Phase I: Immediate Postoperative
harmful to articular cartilage. Period (days first 14)
• If autograft hamstring is harvested and used, avoid
excessive hamstring stretching and strengthening for Goals
the first 6 weeks.
• Pain control
• Reduce swelling and effusion
Anesthesia
• Normalize ROM
• If regional anesthesia is used, await return of full motor • Return of quadriceps activation
function before starting weightbearing exercises.
C LINICAL P EARLS
Before Surgery: Overview of Goals, • If regional anesthesia is used, await return of motor
Milestones, and Guidelines function before starting weightbearing exercises.
• Use leg elevation, circumferential wrap, and cryo-
therapy to reduce swelling and effusion.
• Early ROM is critical to reduce stiffness.
GUIDING PRINCIPLES OF • Avoid hamstring stretches (if autograft is selected).
POSTOPERATIVE REHABILITATION
• The principles of rehabilitation after MPFL recon- Management of Pain and Swelling
struction are similar to those guiding rehabilitation
following other ligamentous reconstructions of the
• Pain and swelling need to be addressed immediately
knee, such as anterior cruciate ligament (ACL).
postoperatively and controlled over the long term.
• Despite differences between MPFL and ACL recon-
Strict elevation of the limb and limited activity in the
struction surgery, there are enough similarities in
first 1 to 2 days postoperatively allows the acute inflam-
postoperative neuromuscular deficiencies to suggest
matory phase to pass without further perturbation by
that strategies found to be successful after ACL
overaggressive therapy. During that time, cryotherapy
reconstruction should be considered for those who
is helpful,9 whether in the form of ice packs or com-
have undergone MPFL reconstruction.
mercially available cold therapy units.
• The keys are to address pain, ROM, quadriceps Details of the Following Treatments That Are
strengthening, and proximal lower limb control. Appropriate to the Phase of Rehabilitation
• Return of full ROM, pain control, and protected
weightbearing are stressed in the early phases of
• The patient is allowed to bear weight as tolerated with
recovery.
crutches with a hinged knee brace locked in extension.
• Progression of strength training and return to
Unlock the hinged knee brace at 2 to 3 weeks as quad
functional activities follows lines of evidence regard-
strength and control returns. MPFL reconstruction is
ing graft necrosis, remodeling, and tunnel ingrowth,
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 C LINICAL P EARLS
limb should be in a brace during weightbearing activi-
ties for 4 to 6 weeks postoperatively or at least until • ROM should be normalized in this phase.
limb control is sufficient to prevent falls and rotational • Quadriceps and hip muscle activation exercises in
stress on the knee. Early weightbearing should follow weightbearing should be emphasized.
a gradual progression from full protection in a rigid • Return of quadriceps function should allow the
brace locked at full extension to an unlocked brace clinician to unlock the brace.
with crutches. Gradual increase to full weightbearing
should be permitted as quadriceps strength is restored.
• Immediate, controlled ROM is not detrimental to fixa-
tion or graft development in well-positioned and Details of the Following Treatments That Are
securely fixed MPFL grafts. Appropriate to the Phase of Rehabilitation
• An early goal of rehabilitation after MPFL reconstruc- • Return of passive flexion can be limited by poor surgi-
tion is to reestablish full knee extension. Unlike ACL cal technique (e. g., misplaced graft) and by pain asso-
reconstruction, return of passive knee extension does ciated with dissection around the medial epicondyle.
not guarantee full active extension. For that to occur, The goal is to exceed 90° flexion within 6 weeks post-
attention must be focused on quadriceps strengthening. operatively. If that goal is achieved, then it has been
Pain and swelling can be mitigated with electrical stim- our experience that limited knee flexion will not be a
ulation, cold therapy, and compression wraps. Passive problem. On the other hand, delay in achieving greater
patellar glides should be instituted as soon as tolerated than 90° of knee flexion may allow scar tissue prolif-
to reestablish normal passive patellar mobility within eration and formation of adhesions around the graft
the trochlear groove in all directions (superiorly, infe- and within the medial knee soft tissues. Manipulation
riorly, medially, and laterally). may be required to regain full knee motion if flexion
• Early application of neuromuscular electrical stimula- past 90° is not accomplished by Week 6.
tion in combination with volitional contraction is used • Exercises to enhance proximal control in weightbear-
to minimize strength loss after surgery.11 ing should be emphasized. As with the nonweightbear-
• Treatment to enhance proximal control can be started ing exercises, the patient must take care to minimize
preoperatively and then immediately after surgery. the contribution of the tensor fascia lata, as contraction
Postoperatively, patients should perform nonweight- of this muscle contributes to medial rotation of the
bearing exercises targeting the hip abductors, external lower extremity.
rotators, and extensors. When performing strengthen-
ing 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
Phase III (weeks 6 to 10)
medial rotation of the lower extremity. Once the patient Goals
can isolate the proximal muscles of interest in non-
weightbearing, progression to weightbearing activities • Normalize gait pattern
can begin. • Normalize hip strength
• Improve quadriceps strength
C LINICAL P EARL
Phase II: Postoperative (weeks 2 to 6)
• As pain and swelling subsides and function returns,
Goals athletes are often tempted to return to their sport
before clearance by their medical team (surgeon,
• Normalize ROM
therapist). Advise the patient to complete their
• Discontinue crutches
rehabilitation before returning to sports.
• Discontinue brace
TIMELINE 28-1: Postoperative Rehabilitation After Proximal Realignment Procedures and Medial Patellofemoral Ligament
(MPFL) Reconstruction
PHASE I (weeks 0 to 4) PHASE II (weeks 4 to 6)
• Weight-bearing as tolerated (WBAT) with crutches; brace locked • Gradually discontinue crutches
in extension • Discontinue brace at 6 wk
• Unlock brace at 2–3 weeks as quad strength and control returns • Normalize ROM
• Passive ROM as tolerated
• Start nonweightbearing exercises targeting hip abductors,
external rotators, and extensors
• Modalities, including cryotherapy and electrical stimulation
• Home exercises:
• Passive knee extension (knee sags)
• Passive knee flexion (heel slides)
• Gentle quadriceps sets
• Patellar mobilization
Details of the Following Treatments that Are

Appropriate to the Phase of Rehabilitation
• Surgery of the extensor mechanism is particularly prone
to causing quadriceps inhibition and dysfunction, and
every effort should be made to regain quadriceps
control, strength, and endurance. Gentle quadriceps
setting exercises should be started immediately after the
surgery to keep the patellar tendon and infrapatellar
fat pad stretched to their full length and to restore
neuromuscular control. 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.10 Resisted quadriceps and hamstring
strengthening should be progressively employed as the
initial pain subsides.
• The primary causes of quadriceps avoidance are pain,
effusion, and quadriceps muscle weakness. As these
impairments are addressed in other aspects of treat-
ment, the clinician should keep in mind that resolution
of symptoms may not readily translate into a normal- FIGURE 28-5. Electromyography biofeedback can be used to facilitate
ized gait pattern. This is particularly evident in a patient quadriceps recruitment during functional tasks. (From Powers CM,
with long-term pain and dysfunction. Movement pat- Souza RB, Fulkerson JP. Patellofemoral joint. In Magee DJ, Zachazewski
JE, Quillen WS, editors: Pathology and intervention in musculoskeletal
terns can be learned, and the patient may need to be rehabilitation. St Louis: Saunders Elsevier; 2008.)
reeducated with respect to key gait deficiencies. Elec-
tromyography (EMG) biofeedback can be an effective
tool for this purpose (Figure 28-5).
• When postoperative quadriceps weakness and neuro-
muscular inhibition are superimposed on poor proxi-
mal control, unprotected weightbearing can result in can cause abnormal loads on the healing graft. This is
abnormal forces on the healing graft. Assuming that 8 important, as many patients with patellofemoral disor-
to 12 weeks are required for tendon-to-bone healing ders have preexisting deficiencies in proximal limb
within tunnels to support graft tension without risk of control that can contribute to these motions.12
slippage13 care is needed to avoid any rotational activ- • Facilitation of normal gait is an essential component
ity during the first three postoperative months. Unpro- of the overall treatment plan. This is particularly
tected single-leg stance on the operated knee should be important for the returning athlete (especially runners)
avoided until satisfactory proximal limb control has in whom even a slight gait deviation can be com-
been achieved. The postoperative brace should be pounded by repetitive loading. The clinician should
removed for resisted flexion and extension strengthen- pay particular attention to the quadriceps avoidance
ing and other controlled rehabilitative exercises that do gait pattern (walking with the knee extended or hyper-
not cause knee valgus or axial rotational torque that extended). Because knee flexion during weight accep-
would jeopardize the graft fixation. tance is critical for shock absorption,14 this key function
• Care should be taken during weightbearing to prevent must be restored to prevent the deleterious effects of
dynamic knee valgus and hip internal rotation, which high-impact tibiofemoral joint loading.
TIMELINE 28-1: Postoperative Rehabilitation After Proximal Realignment Procedures and Medial Patellofemoral Ligament
(MPFL) Reconstruction (Continued)
PHASE III (weeks 6 to 10) PHASE IV (weeks 10 to 14) PHASE V (weeks 14 to 24)
• Normalize gait • Functional and proximal control training • Normalize strength and power of all
• Normalize hip strength • Weightbearing strength training of major muscle groups
• Improve quadriceps strength quadriceps, core, and hip stabilizers • Dynamic limb control during sport-
• Single-leg strength, balance, and control specific activities
exercises • Movement activities that simulate
• Plyometrics and sport-specific training demands of their sport
• Return to their sport or activity gradually
• Plyometric training (e.g., jump training)
• Maintain quadriceps and hip muscle
strength (e.g., maintenance program)
Phase IV: Postoperative Phase V: Postoperative

(weeks 10 to 14) (weeks 14 to 24)
Goals Goals
• Symmetric and normalized dynamic limb stabilization • Normalized strength and power of all major muscle
and control (single leg) groups
• Normalized quadriceps strength • Dynamic limb control during sport-specific activities
• No evidence of hip internal rotation or dynamic knee
valgus during sport-specific activities
C L I NICAL P EAR L S
C LINICAL P EARLS
• Focus on functional training, dynamic limb stabi-
lization, and control. • The athlete should begin to engage in movement
• Perform closed-chain quadriceps strengthening; activities that simulate demands of their sport.
avoid open-chain knee extension exercises. • The athlete should be closely monitored for poor
• Unprotected single-leg stance on the operated knee lower limb mechanics during this phase of
should be avoided until satisfactory proximal limb rehabilitation.
control has been achieved.
Details of the Following Treatments That Are

Appropriate to the Phase of Rehabilitation
Details of the Following Treatments That Are • Patients are encouraged to return to their sport or
Appropriate to the Phase of Rehabilitation activity gradually once they can achieve satisfactory
• Functional training of the limb can begin in earnest single-limb dynamic control. With competitive or rec-
3 months after surgery. At this time, the patient reational athletes who will be returning to full partici-
should be introduced to the concept of neutral lower pation, plyometric training (e.g., jump training) should
extremity alignment. This involves alignment of the be considered during this phase of the rehabilitation
lower extremity such that the anterior superior iliac program. As patients, particularly athletes, return to
spine (ASIS) and knee remain positioned over the sport activities, repetitive forces applied through the
second toe, with the hip positioned in neutral. Postural knee joint must be controlled adequately to allow con-
alignment and symmetrical strengthening should be tinued healing of the injured or repaired tissues. Quad-
emphasized during all exercises (see previous section of riceps and hip muscle strength should be maintained
this chapter). (e.g., maintenance program).
• Femoral strapping can be used to provide kinesthetic
feedback and to augment muscular control and pro- Criteria for Return to Sport
prioception. Taping or bracing can also be used if pain
is limiting the patient’s ability to engage in a meaning- • Return to sport criteria:
ful weight-bearing exercise program. • Full and painless ROM
• Partial squats, which may have started already in a • Absence of effusion and swelling
very controlled environment with supervision, can be • Satisfactory and symmetric proximal single-limb
advanced to incorporate a BOSU ball, or similar device, dynamic control during high-impact activities (e.g.,
to facilitate proximal control. Close supervision is landing from a jump, cutting, etc.)
encouraged to ensure proper execution of these exer- • Quadriceps, hamstring, and hip strength in at least
cises. Once the patient understands the proper move- 90% of uninjured leg
ment and goal of the task, continued performance in • Psychologically ready to return to sports
front of a mirror provides useful feedback. • Patients can expect to return to unrestricted activities
• As strength, control, and balance progress, single-leg 6 months to 1 year postoperatively.
activities may be initiated. This is the final step before
returning to full unrestricted activity. Considering that
most patients are conditioned by their preoperative Evidence
apprehension caused by patellar instability and some
patients may not have performed single-leg squats on Chen V, Chacko AT, Costello FV, et al: Driving after musculo-
the operated leg for years before the operation, the skeletal injury. Addressing patient and surgeon concerns in an
patient may not progress to this stage before 5 to 6 urban orthopaedic practice. J Bone Joint Surg Am 90:2791–
months after the reconstruction. In any case, rehabilita- 2797, 2008.
tion from this point onward requires careful assess- The authors report on two surveys (one administered to
ment and progressive development of proximal lower patients, one to surgeons) regarding return to driving and the
limb control. impact of musculoskeletal injury on driving. Overall, 73% of
patients reported that the inability to drive presented a minor follow-up at an average of 4 years postoperatively. The
or major difficulty, and greater than 35% of patients either patients underwent an accelerated rehabilitation protocol
began driving while still on narcotics or did not consult their with strengthening and functional agility occurring at weeks
doctor before driving. The authors highlight the medicolegal 2 to 5 and return to sport-specific activities at 5 weeks if
ramifications regarding the issues around returning to drive quadriceps strength was sufficient. Mean time to completing
and describe the process that their institution used to develop at 100% was 6.2 months. Graft ruptures occurred in 2.6%
standardized guidelines. The need for standardized guidelines of the patients, and 97% to 98% of patients (both acute and
from a large professional organization was emphasized. chronic) had KT arthrometry side-to-side differences of less
(Level V evidence) than 5 mm. (Level IV evidence)
Nomura E, Hoiuchi Y, Kihara M: A mid-term follow up of Souza RB, Powers CM: Differences in hip kinematics, muscle
medial patellofemoral ligament reconstruction using an artifi- strength, and muscle activation between subjects with and
cial ligament for recurrent patellar dislocation. Knee 7:211– without patellofemoral pain. J Orthop Sports Phys Ther 39:12–
215, 2000. 19, 2009.
Case series of 27 MPFL reconstructions at average follow-up This is a laboratory study comparing the hip biomechanics
of 5.9 years. A double-staple fixation method was used to fix of 20 asymptomatic females with 21 females with patello-
the artificial ligament at 60° of knee flexion with a minimal femoral pain. Motion analysis and EMG of the gluteus
amount of tension (a tension spacer was placed to ensure that maximus and gluteus medius were used to analyze the bio-
it was not overtightened). The authors report 96% good to mechanics during running, drop jumps, and step-downs. Hip
excellent results, with only one case of recurrent patellar abductor and hip extension isometric strength was also tested
subluxation/dislocation and two cases with positive appre- using a dynamometer. Subjects with patellofemoral pain had
hension tests. Symptomatic implants (staples) were the most a higher degree of peak hip internal rotation during the tests
frequent complication. (Level IV evidence) and lower peak hip abduction and extension torques in
strength testing. The authors conclude that an assessment of
Palmieri-Smith RM, Kreinbrink J, Ashton-Miller JA, et al: hip kinematics and strength is critical in patients with patel-
Quadriceps inhibition induced by an experimental knee joint lofemoral pain. (Level V evidence)
effusion affects knee joint mechanics during a single-legged
drop landing. Am J Sports Med 35:1269–1275, 2007. Steinkamp LA, Dillingham MF, Markel MD, et al: Biomechani-
Laboratory study involving nine active subjects in which four cal considerations in patellofemoral joint rehabilitation. Am J
experimental knee conditions were tested in the same subjects Sports Med 21:438–446, 1993.
with a washout period: no effusion, subcutaneous lidocaine This is a biomechanical study of 20 patients comparing patel-
injection, low effusion (30 ml), and high effusion (60 ml). lofemoral joint forces performing leg extension exercises
Using electromyographic, motion analysis, and force mea- versus incline leg presses. At 0° and 30°, knee moments,
surements, the subjects were analyzed doing drop landings. patellofemoral joint reaction forces, and patellofemoral joint
Both the high- and low-effusion conditions had significantly stress values were higher during leg extensions than during
impaired vastus lateralis and vastus medialis muscle activity, leg presses. At 60° and 90°, patellofemoral stress, joint reac-
but only the high-effusion condition had a significant increase tion force, and knee moments were higher for leg presses. The
in net ground reaction force and corresponding decreases in crossover points were between 46° and 51°, with the intersec-
net knee extension moment and peak knee flexion angle. The tion occurring at 48.4° for patellofemoral joint stress. Leg
results indicate that larger effusions lead to altered biome- presses are recommended for rehabilitation of patellofemoral
chanics, muscle activation, and landing forces. (Level V pain because of the lower patellofemoral joint stress values
evidence) at lower (functional) ranges of motion. (Level V evidence)
Rodeo SA, Arnoczky SP, Torzilli PA, et al: Tendon-healing in a
bone tunnel. A biomechanical and histological study in the dog.
J Bone Joint Surg Am 75:1795–1803, 1993. REFERENCES
1. Bassett FH: Acute dislocation of the patella, osteochondral frac-
This is a study of 20 dogs that underwent bilateral transplan-
tures, and injuries to the extensor mechanism of the knee. In Burke
tation of the long digital extensor tendon from the lateral E, editor: American Academy of Orthopedic Surgeons Instructional
femoral condyle into a tunnel through the proximal tibial Course Lectures, St. Louis, 1976, C. V. Mosby, Inc., pp 40–49.
metaphysis, with fixation on the medial tibia. At 2, 4, 8, 12, 2. Teitge RA, Faerber WW, Des Madryl P, et al: Stress radiographs of
and 26 weeks, biomechanical and histologic analysis was the patellofemoral joint. J Bone Joint Surg Am 78:193–203, 1996.
performed after sacrifice. Over the postoperative period, the 3. Fithian DC, Mishra DK, Balen PF, et al: Instrumented measurement
tendon–bone interface transformed from fibrous tissue to of patellar mobility. Am J Sports Med 23:607–615, 1995.
more organized collagen fibers with significant remodeling of 4. Muneta T, Sekiya I, Tsuchiya M, et al: A technique for reconstruc-
the trabecular bone. The most dramatic increase in the tion of the medial patellofemoral ligament. Clin Orthop Relat Res
359:151–155, 1999.
strength of the interface occurred during the first 4 weeks. All
5. Nomura E, Hoiuchi Y, Kihara M: A mid-term follow up of medial
specimens through 8 weeks failed at the tendon–bone inter- patellofemoral ligament reconstruction using an artificial ligament
face, whereas at 12 and 26 weeks, failure occurred from for recurrent patellar dislocation. Knee 7:211–215, 2000.
slippage at the clamp or from midsubstance rupture. The 6. Nomura E, Hoiuchi Y, Kihara M: Medial patellofemoral ligament
authors recommend protecting a healing tendon–bone inter- restraint in lateral patellar translation and reconstruction. Knee
face for 8 to 12 weeks postoperatively. (Level V evidence) 7:121–127, 2000.
7. Palmieri-Smith RM, Kreinbrink J, Ashton-Miller JA, et al: Quad-
Shelbourne KD, Gray T: Anterior cruciate ligament reconstruc- riceps inhibition induced by an experimental knee joint effusion
tion with autogenous patellar tendon graft followed by acceler- affects knee joint mechanics during a single-legged drop landing.
ated rehabilitation. A two- to nine-year followup. Am J Sports Am J Sports Med 35:1269–1275, 2007.
Med 25:786–795, 1997. 8. Chen V, Chacko AT, Costello FV, et al: Driving after musculoskel-
etal injury. Addressing patient and surgeon concerns in an urban
This study is a case series of 1057 patients with ACL recon- orthopaedic practice. J Bone Joint Surg Am 90:2791–2797,
structions with 76% objective follow-up and 90% subjective 2008.
9. Shelbourne KD: Anterior cruciate ligament reconstruction with QUESTION 4. ROM exercises after MPFL reconstruction
autogenous patellar tendon graft followed by accelerated rehabili- should start:
tation. A two- to nine-year followup. Am J Sports Med 25:96–98,
1997. A. Three weeks after surgery to avoid detrimental
10. Steinkamp LA, Dillingham MF, Markel MD, et al: Biomechanical effects to MPFL fixation at the patella
considerations in patellofemoral joint rehabilitation. Am J Sports B. Six weeks after surgery to avoid detrimental
Med 21:438–446, 1993. effects to MPFL fixation at the femur
11. Manske R, DeCarlo M, Davies G, et al: Anterior cruciate ligament
reconstruction: rehabilitation concepts. In Kibler W, editor: Ortho- C. Immediately but must be controlled
paedic Knowledge Update: Sports Medicine 4, ed 4, Rosemont, IL, D. Once proximal single-limb dynamic control has
2009, American Academy of Orthopaedic Surgeons, pp 247–256. been attained
12. Souza RB, Powers CM: Differences in hip kinematics, muscle
strength, and muscle activation between subjects with and without QUESTION 5. The final step before return to full unre-
patellofemoral pain. J Orthop Sports Phys Ther 39:12–19, 2009. stricted activity is:
13. Rodeo SA, Arnoczky SP, Torzilli PA, et al: Tendon-healing in a bone
tunnel. A biomechanical and histological study in the dog. J Bone A. Normalized gait pattern
Joint Surg Am 75:1795–1803, 1993. B. Absence of effusion and swelling
14. Perry J, Antonelli D, Ford W: Analysis of knee-joint forces during C. Single-leg activities to achieve symmetric
flexed-knee stance. J Bone Joint Surg Am 57:961–967, 1975.
proximal single-limb dynamic control during
high-impact activities
D. Removal of postoperative bandages
Multiple-Choice Questions
QUESTION 1. Choose the best indication for MPFL
reconstruction:
Answer Key
A. Patellofemoral pain QUESTION 1. Correct answer: C (see Indications for
B. First-time lateral patellar dislocation Surgical Treatment)
C. Episodic lateral patellar instability
D. Episodic medial patellar instability QUESTION 2. Correct answer: C (see Brief Summary of
Surgical Technique)
QUESTION 2. If an autograft hamstring is harvested and
used to reconstruct the MPFL, avoid: QUESTION 3. Correct answer: C (see Postoperative
A. Regional anesthesia Rehabilitation: Overview of Goals, Important Mile-
B. Immediate ROM stones, and Guidelines)
C. Excessive hamstring stretching and QUESTION 4. Correct answer: C (see Postoperative
strengthening for the first 6 weeks Rehabilitation: Overview of Goals, Important Mile-
D. Quad setting for the first 12 weeks stones, and Guidelines [Range of Motion])
QUESTION 3. The principles that guide rehabilitation QUESTION 5. Correct answer: C (see Postoperative
after MPFL reconstruction are similar to those guiding Rehabilitation: Overview of Goals, Important Mile-
rehabilitation after which type of surgery? stones, and Guidelines [Dynamic Limb Stabilization
A. Tibial tubercle osteotomy and and Control])
anteromedialization
B. Lateral retinacular release and medial reefing
C. Anterior cruciate ligament reconstruction
D. Total knee arthroplasty
POSTOPERATIVE REHABILITATION AFTER

ANTEROMEDIALIZATION OF THE TIBIAL TUBERCLE
John Pryor Fulkerson, MD, Craig Alver, PT, and Erin L. Ives, PT, MS, OCS, CertMDT
Indications for Surgical Treatment Brief Summary of Surgical Treatment

• Excessive lateral patella compression syndrome Major Surgical Steps
• Lateral patellofemoral arthrosis
• Lateral patella tracking with lateral articular breakdown • Oblique osteotomy behind the tibial tubercle, tapered
• Painful distal and/or lateral patella chondral articular anteriorly at the distal aspect1
softening that has not responded to nonoperative or • Transfer the tibial tubercle anteriorly and medially by
arthroscopic treatment rotation of the osteotomy through a distal hinge of bone
needs to be performed often (2 to 3 times a day) to

gain the best results. Surgical fixation should permit
this early motion.
Goals
• Protect the reconstruction
• Minimize pain and swelling in the lower extremity
• Initiate ROM exercises to promote healthy scar tissue
FIGURE 28-6. Surgical incision. Protection

• Protection of the reconstructed knee includes the use
of bilateral axillary crutches with a knee immobilizer.
• Secure fixation with two cortical lag screws into the • Weightbearing status is touch-toe weightbearing
posterior tibial cortex with compression (Figure 28-6) (TTWB) with a maximum of 20 lb exerted through the
affected LE.
Factors That May Affect Rehabilitation Management of Pain and Swelling

Anesthetic • Modalities including cryotherapy, TENS, and IFC stim-
• Regional block will impair early motion in the first 24 ulation; oral pain medications
to 48 hours but will be very helpful for immediate • Cryotherapy, elevation, high-volt electrical stimulation,
postoperative pain control Kinesio taping (Figure 28-7)
Surgical Techniques for Progressive Increase in
• Fixation that is less secure or bone graft added in the Range of Motion
osteotomy may require a longer period of limited
motion and therefore impede the rehabilitation process Manual Therapy Techniques
• Mobilize the patella in inferior and superior directions
along with correcting for any positional faults that may
be present, such as lateral tilt
GUIDING PRINCIPLES OF
POSTOPERATIVE REHABILITATION Soft Tissue Techniques
• Myofascial release and soft tissue mobilization around
• Understand the process of the surgical incision when proper healing has occurred
reconstruction
• Protect and progress ROM as appropriate for the
healing bone and soft tissues
• Identify and correct lower extremity (LE) muscle
imbalances
Phase I: Immediate Postoperative

Period (days 0 to 14)1
C LINICAL P E A R L
It is important during the immediate postoperative
period to emphasize to the patient the importance of
regaining full range of motion as quickly as possible.
The patient needs to be instructed to bend the knee
to a point that produces some level of discomfort that
subsides once the stretch is completed. Stretching
1
Prehabilitation, if appropriate, is described in the Nonoperative Reha-
bilitation section of this chapter. FIGURE 28-7. Kinesio tape positioning for edema reduction.
Stretching and Flexibility Techniques for the Goals

Musculotendinous Unit • Continue to protect the reconstruction
• Gastrocnemius, hamstring, iliotibial band (ITB), and • Minimize pain and swelling in the lower extremity
hip flexor stretches to promote knee extension and • Achieve full knee extension to flexion ROM
quadriceps stretching to promote knee flexion; ankle • Initiate open-chain LE strengthening exercises
pumps for thrombosis prevention
Protection
Activation of Primary Muscles Involved in
• Protection continues with the use of bilateral axillary
Injury Area or Surgical Structures
crutches
• Quadriceps, gluteal, and hamstring setting exercises • Weightbearing can increase to partial weightbearing
should be initiated (PWB) 50% of body weight
Milestones for Progression to the Next Phase Management of Pain and Swelling
• Achieve 0° to 90° of knee active range of motion • For pain: modalities including cryotherapy, TENS, and
(AROM) by 6 weeks from the date of surgery and full IFC stimulation
motion by 8 to 10 weeks • Oral pain medications.
• Demonstrate independence with thrombosis preven- • For swelling: modalities including cryotherapy, high-
tion measures and ROM exercises volt electrical stimulation, and Kinesio taping
• Independent use of bilateral axillary crutches with
TTWB through affected LE Techniques for Progressive Increase in
Range of Motion
Phase II: Postoperative (weeks 2 to 6) Manual Therapy Techniques

• Mobilize the patella in superior and inferior directions
progressing the inferior glide with varying angles of
C L I NICAL P EAR L knee flexion to promote full knee flexion AROM
During this phase, OKC exercises for the hip are initi- Soft Tissue Techniques
ated, and correct form is crucial to good outcomes.
• Myofascial release and soft tissue mobilization around
Compensations in the form of faulty movement pat-
the incision is continued in this phase to help promote
terns will occur and need to be noted and corrected
return of full extension to flexion knee range of motion
by the therapist. During side-lying abduction, the
(ROM)
therapist needs to be sure that the patient is actually
abducting from the hip joint and not compensating Stretching and Flexibility Techniques for the
with lumbar side bending. During the side-lying Musculotendinous Unit
clamshell exercise, the therapist also needs to be sure
• The stationary bike is a great tool for working flexion
that the movement occurring is hip rotation and not
ROM at this time. The patient will begin with a rocking
lumbar spine rotation. These compensations may
motion, inducing a flexion stretch in both forward
result in low back pain and a prolonged recovery for
and reverse directions until a complete revolution is
your patient.
possible.
TIMELINE 28-2: Postoperative Rehabilitation After Anteromedial Tibial Tubercle Transfer

PHASE I (weeks 0 to 2) PHASE II (weeks 2 to 6) PHASE III (weeks 6 to 10)
• Knee immobilizer • Weightbearing can increase to PWB 50% • FWB without assistive device with
• TTWB with bilateral axillary crutches of body weight with bilateral axillary normal gait pattern
• PT modalities crutches • PT modalities
• ROM (goal of 90°) • PT modalities • Patella mobilization as needed
• Patella mobilization as needed • Patella mobilization as needed • Initiate CKC exercises for strength,
• TBS/TAS/TLS as recommended and • Achieve full knee extension-to-flexion balance, and proprioception
tolerated ROM • Maintain full knee extension-to-flexion
• Thrombosis prevention • Initiate OKC LE strengthening exercises ROM
• LE stretches are continued, including the hamstring, Goals

gastrocnemius, quadriceps, and hip flexor muscle
groups, until full ROM is achieved at the knee. • Normalize gait without assistive devices
• Initiate CKC exercises for strength, balance, and
proprioception
• Maintain full knee extension to flexion ROM
• Quadriceps, hamstring, and gluteal setting exercises Protection
continue and progress to open-chain exercises outlined
in the following sections • The patient should be weaning from crutches at this
point, with an emphasis placed on normalizing the gait
pattern by the end of this phase. The patient will now
Open and Closed Kinetic Chain Exercises
be weightbearing as tolerated (WBAT) through the
• OKC exercises, including straight leg raise (SLR) into affected LE with the use of bilateral axillary crutches
flexion, abduction, adduction, and extension progressing to one crutch WBAT and finally to fulll
• OKC and CKC exercises to address the hip muscles, weightbearing (FWB) at 10 weeks.
including the clamshell and bridge
Milestones for Progression to
• Cryotherapy after therapy interventions to mitigate
the Next Phase
inflammation and soreness
• Full knee extension to flexion ROM • If swelling persists into this phase, the use of cryo-
• SLR in four directions without extension lag therapy with high-volt stimulation can be effective
• Effective use of crutches with PWB at 50%
Techniques for Progressive Increase in
Range of Motion
Phase III: Postoperative Manual Therapy Techniques
(weeks 6 to 10)
• Continue to monitor movement of the patella; at this
point, grade 1 to 4 mobilizations of the knee for flexion
C LINICAL P E A R L S or extension can be initiated
It has been documented that there is a correlation Soft Tissue Techniques
between hip ER weakness and patellofemoral dys-
• Soft tissue mobilizations and myofascial release would
function.2 As strengthening is progressed with CKC
be beneficial for any remaining adhesions
activity in this phase, it is important to be aware of
the patient’s movement patterns. A common faulty Stretching and Flexibility Techniques for the
movement pattern includes IR of the femur with a Musculotendinous Unit
valgus movement at the knee. Correct activation
• The stationary bike is continued at this time, with
of the hip ER can decrease this faulty movement
the patient making full revolutions with increasing
pattern.
resistance
TIMELINE 28-2: Postoperative Rehabilitation After Anteromedial Tibial Tubercle Transfer (Continued)
PHASE IV (weeks 10 to 14) PHASE V (weeks 14 to 24) PHASE VI (weeks 24 to 52)
• PT modalities as needed • Continue modalities and mobilizations • Maintain full ROM
• Mobilizations as needed (patellofemoral as needed • Continue OKC and CKC exercises as
and tibiofemoral) • Initiate partial lunges appropriate
• Achieve normal gait pattern if not yet • Initiate walk-run program at 4 months • Progress to full lunges with varying
achieved • Initiate SLB exercises on even and directions
• A/PROM to full if not yet achieved uneven surfaces • Progress plyometrics
• Initiate prone quadriceps stretching • Initiate plyometrics at 5 months • Increase speed of sport-specific exercises
• CKC: Leg presses and squats • Initiate slide board activity at 16 to • Increase jogging time speed
• OKC: May begin lightweight knee 20 weeks • Progress in-line running speed
extensions at 10 to 12 weeks • Slow-speed sport-specific exercise at 20 • Return to in-line running full speed
• OKC: Hamstrings and hip PREs weeks • Return to limited sports with warning of
• Controlled balance and proprioception • Continue with OKC and CKC exercises risks
exercises • Full torsional sport (plant and cut)
• Begin upper-body strengthening and usually delayed until 1 yr after
endurance activities osteotomy
• Aquatic therapy may start as long as
incision is healed
Sensorimotor Exercises • Strength MMT 4/5 for quadriceps and hamstrings

• Climb stairs reciprocally without pain
• Initiate balance and proprioception exercises for the LE
seated on a therapy ball, then progress to single-leg Management of Pain and Swelling
stance (SLS) with the contralateral LE in a toe-touch
position and, finally, SLS on the affected LE with a goal • Cryotherapy after interventions to mitigate inflamma-
of maintaining the position for 30 seconds tion and soreness
• If swelling persists into this phase, the use of cryo-
therapy with high-volt stimulation can be effective
• Continuation of SLR in four positions of hip flexion, Techniques for Progressive Increase in
extension, abduction, and adduction with the addition Range of Motion
of an ankle weight once extension lag is no longer
present • If ROM in the knee is not yet full, then it will continue
• Clamshell with a weight above the knee for an added to be addressed.
challenge
• Bridge progression to bridge with marching Manual Therapy Techniques
• Joint mobilization if needed for flexion and extension
• Patella mobilization if needed
Techniques to Increase Muscle Strength,
• Often times, ROM is WNL and the patella is moving
Power, and Endurance
well by this point in rehabilitation
• The stationary bike at this point can be used for endur-
ance with increasing resistance as tolerated Soft Tissue Techniques
• If the incision remains tight, scar mobilization can be
used
Functional Exercises
• Sit to stand from chair Stretching and Flexibility Techniques for the
• Two-inch step exercises, including anterior step-up, Musculotendinous Unit
lateral step-up, and retro step-up • Quadriceps stretching (in prone) (Figure 28-8)
• Hamstring, gastrocnemius, and hip musculature
self-stretching
the Next Phase
Other Therapeutic Exercises
• FWB without assistive device with normal gait pattern
• Full extension to flexion ROM of the knee is • Increase LE closed-chain strengthening
maintained • Slowly progress to proprioceptive activities in
• SLS with eyes open for 30 seconds standing
• Begin upper-body strengthening and endurance
exercises
Phase IV: Postoperative
(weeks 4 to 6) Activation of Primary Muscles Involved in
C L I NICAL P EAR L
• Leg presses/partial squats for quadriceps strengthening
The literature has demonstrated improved knee func- are introduced
tion as a result of LE stretching, specifically at the
hip.3 As early as possible in this phase, prone quad-
riceps stretching should be initiated. Stretching the
quadriceps in this position helps to stabilize the hip
and decrease the potential for tortional forces on the
knee. It also makes it easier to detect any rotation at
the hip (ER/IR), which should be avoided. Passive
knee flexion of 90° in prone by the therapist should
be achieved before having the patient stretch inde-
pendently. For comfort, a folded towel may be put
under the thigh, raising it slightly off the table/floor.
Goals
• Normal gait if this has not been achieved
• Full pain-free ROM if this has not been achieved FIGURE 28-8. Prone quadriceps self-stretch using a strap.
• Begin step-ups/step-downs
• Increase knee, hip, and calf strengthening
Sensorimotor Exercises
• Single-leg balance with eyes open and contralateral LE
in toe-touch position
• Progress to single-leg balance (SLB) with eyes open and
no contralateral involvement with the goal of main-
taining position for 30 seconds

• OKC: Continuation of SLR in four positions and other FIGURE 28-10. Hamstring curl with legs on therapeutic ball.
previous OKC exercises with increasing weight
• OKC: Open-chain light quadriceps strengthening can
be started at 10 to 12 weeks postop. Open-chain quad- Techniques to Increase Muscle Strength,
riceps exercises should be initiated with light weight, Power, and Endurance
10 to 15 reps, and should be pain free
• OKC: Hamstring curls, seated • Increase resistance and time on bike as tolerated
• CKC: Leg presses/partial wall squats, hip extension, • May begin using elliptical machine
calf raises. Advance to single-leg squats and calf raises • Increase walking time and speed slowly
as tolerated. Squats should initially be stopped at 50°
to 60° of knee flexion, as research suggests that there Neuromuscular Dynamic Stability Exercises
is less patellofemoral joint force in this range and that
it increases between 60° and 90°.4 • In standing, begin SLR in four directions with resisted
• Also, because the goal is to restore quadriceps strength tubing on surgical leg. This will improve balance and
and correct patella tracking, there is research to support will facilitate core recruitment for total body stability.
using isometric hip adduction with squats to help elicit • Also, exercises such as bridges on a Thera-Ball and
the VMO and promote patella tracking.5 (Figure 28-9) hamstring curls on a Thera-Ball can be started, as they
• CKC: Step-ups/step-downs, usually starting with a will also introduce core stability while working on LE
4-inch step. With step work, care should be taken to strength (Figure 28-10).
have the patient adduction and internal rotation of the
hip Functional Exercises
• CKC: Terminal knee extension with foot on ground,
resistance behind knee • Step-ups and step-downs on stairs (start with 4-inch
• Pool-based exercises for the UE and LE may be started step)
at this point as long as the incision is healed • Make sure that technique is monitored
• Avoid hip adduction and internal rotation of the hip
Sport-Specific Exercises
• UE sport-specific drills for coordination can be started
in a controlled environment, either sitting or standing
on both legs
Milestones for Progression to the Next Phase

• Pain-free normal gait
• Able to climb stairs reciprocally without pain
• 4/5 quadriceps and hamstring strength
• Single-limb balance greater than 1 minute
Phase V: Postoperative
(weeks 14 to 24)
C LINICAL P EARLS
With the patient advancing to balance activities and
increased dynamic stabilization exercises such as
FIGURE 28-9. Wall squat with isometric hip adduction.
lunges, great care needs to be placed on educating the

patient in proper technique. Good alignment of the
knee in relation to the hip and foot must be stressed.
For instance, research has shown that a longer step
with the lunge produces less patellofemoral joint
force.6
Additionally, when higher-level dynamic stability
exercises are initiated, it is imperative that form be
monitored. In weightbearing, hip IR and adduction
should be avoided when balancing, squatting, and
jumping, as this can lead to lateral patella tilt and
displacement.7
Goals
• 5/5 strength in quadriceps, hamstrings, and all hip
musculature FIGURE 28-11. Single-leg stance with bilateral upper extremity reach.
• Single-limb balance of 2 minutes
• Return to jogging
• Add SLS with UE weighted ball toss against rebounder,

standing on flat surface.
• Ice after exercise • Slide board activity may be started between 16 and 20
weeks postoperatively. Balance on uneven surfaces,
such as Airex foam or DynaDisc and exercises on a
BOSU ball may also be initiated at this time (Figure
Range of Motion
28-12).
• Patients should have achieved full ROM by now. If not,
follow previous guidelines. Open and Closed Kinetic Chain Exercises
Manual Therapy Techniques • OKC: Progress to standing hip exercises with resistance
• Continue previous techniques as needed from bands or machines
• OKC: Progress hamstring curls
Soft Tissue Techniques • OKC: Progress knee extension exercises. Stay with 10
• Scar mobilization if required to 15 reps for three sets and continue to lower
resistance
Stretching and Flexibility Techniques for the • CKC: Lunges, starting forward and progressing as tol-
Musculotendinous Unit erated. Oftentimes, it is necessary to start with partial
• Continue with previous stretching of lower extremities
bilaterally

• Progress previous LE strengthening
• Progress UE strengthening
• Initiate neuromuscular dynamic stability exercises
• Initiate walk/run program at 4 months
• Initiate plyometric exercises at 4 months

• As before with progressive resistance
Sensorimotor Exercises
• Initiate SLB activities on uneven surfaces at 16 weeks.
• Initiate SLS exercises with a progression of opposite LE
reach, bilateral UE reach, and weighted bilateral UE
reach as tolerated, focusing on good control of the knee
in relation to the foot and hip (Figure 28-11). FIGURE 28-12. Squat on BOSU ball.
FIGURE 28-13. A, Partial lunge. B, Full lunge with long A B

stride.
lunges (Figure 28-13). Of note: research supports a Neuromuscular Dynamic Stability Exercises
longer stride when performing a lunge to decrease the
patellofemoral compressive force. Over time, a medi- • Forward and sideways lunge on BOSU ball
cine ball with upper extremity reaching may be added • SLS with ball toss on uneven surfaces (Figure 28-15)
to the lunge to incorporate core stabilization (Figure • Squats on BOSU ball; SLB on BOSU ball
28-14).
• CKC for upper body and core, such as pushups and Plyometrics
planks, may be started
• Begin light plyometrics at 5 months as long as patient
is pain free. Focus first on technique. Make sure the
Techniques to Increase Muscle Strength,
landing is soft and that the femur is not internally
Power, and Endurance
rotating or adducting (Figure 28-16).
• Increase weight on resistance exercises • Slowly progress plyometrics, always focusing on form.
• Initiate a walk/run program at 4 months. To do this, • Begin with bilateral jumps, progressing to toe taps on
the patient must be pain free during a fast walk (at least steps, step-ups, and step-overs and progress to one leg
3.5 mph) only as patient’s control allows.
FIGURE 28-15. Single-leg balance on DynaDisc with ball toss against

FIGURE 28-14. Lunge with upper extremities holding medicine ball. rebounder.
Goals
• Return to in-line running full speed
• Return to limited sports with warning of risks
• Full torsional sport (plant and cut) usually delayed
until 1 year after osteotomy

• Ice as needed after exercise

Range of Motion
• ROM should be full and pain free at this point.
Stretching and Flexibility Techniques for the

Musculotendinous Unit
A B • Patient should be instructed in the necessity of continu-
ing LE stretching before and after exercise
FIGURE 28-16. A, Correct landing. B, Incorrect landing with right hip
slightly adducted and internally rotated.
Functional Exercises • The focus in this phase should be to get UE and LE

strength back to preinjury levels.
• Begin step-ups and step-overs, starting on a step and
progressing to BOSU ball. Activation of Primary Muscles Involved in
• Begin a walk/run program at 20 to 24 weeks as long Injury Area or Surgical Structures
as the patient is pain free.
• Continue to strengthen quadriceps, hamstring, and hip
musculature, progressing weight as tolerated.
Sport-Specific Exercises
• Continue sport-specific exercises for UEs Sensorimotor Exercises
• May initiate slow-speed agility activities at 20 weeks if
jogging and plyometrics have been pain free. These • Advance balance and proprioceptive exercises to
may include side shuffling, figure-eights, side-to-side tolerance
carioca, etc.
• OKC: Continue open-chain quadriceps, hamstring,
the Next Phase
and hip exercises
• 5/5 strength throughout lower extremity • CKC: Progress squats and leg presses to tolerance
• Pain-free jogging
• Single-leg balance of 2 minutes Techniques to Increase Muscle Strength,
• Able to jump and land with good control pain free Power, and Endurance
• Increase jogging time and speed
Phase VI: Postoperative • Progress in-line running time and speed to tolerance
(weeks 24 to 52)
Neuromuscular Dynamic
C L I NICAL P EAR L Stability Exercises
• Single-leg stance with UE band pulls, increasing resis-
Progression in this phase varies widely. It is not
tance as control and balance allow
uncommon for an athlete who plays a contact sport
to be out a full year before returning to the game. It
is important to explain this to the patient early on Plyometrics
and to set goals appropriately. Progression during
• Advance plyometric exercises to tolerance, still focus-
this phase with regard to jumping, cutting, and speed/
ing on good control of the knee in relation to the foot
agility exercises must be slow and controlled.
and hip
Escamilla RF, Zheng N, Macleod TD, et al: Patellofemoral joint

Sport-Specific Exercises force and stress during the wall squat and one-leg squat. Med
• During this phase, sport-specific exercises should be Sci Sports Exerc 41:879–888, 2009.
initiated, starting at slow speed and then increasing Research study using 18 subjects and 12 repetition max
speed in a slow, progressive manner weight while performing wall squat short and long, as well
as one leg squat. The study used EMG, force platform,
and kinematic variables to calculate patellofemoral com
Milestones for Progression to pressive forces and stress as a function of the knee angle.
the Next Phase Results of the study found that patellofemoral force and
stress were greater with these exercises between 60° and
• If isokinetic testing is available, less than 10% deficit 90°, with differences depending on the exercise. (Level II
of the involved side when compared to the noninvolved evidence)
side
• No pain with agility/speed training activities Farr J, Schepsis A, Cole B, et al: Anteromedialization, review
and technique. J Knee Surg 20:120–128, 2007.
In this article, the authors share their extensive experience
with the procedure to present the proper use and implementa-
Criteria for Return to Sport tion of tibial tubercle ateromedialization. In essence, the pro-
cedure is best used to realign a chronically lateral overloaded
General patella that has led to lateral and/or distal patella articular
breakdown and pain. The procedure effectively unloads the
• Full motion and strength return lateral and distal patella, thereby affording substantial pain
• Solid evidence of radiographic consolidation of the relief and patellofemoral balance to the patient when the
osteotomy surgery and rehabilitation are properly performed. (Level III
• Perform full-speed, sport-specific agility drills without evidence)
pain
Ireland ML, Willson JD, Ballantyne BT, et al: Hip strength in
females with and without patellofemoral pain. J Orthop Sports
Sport-Specific Phys Ther 33:671–675, 2003.
• The rehabilitation specialist and athletic trainers This is a cross-sectional design study involving 30 females,
15 with knee pain and 15 without knee pain. Hip ER and
should, at this point, be able to develop a series of tests
ABD strength were measured using a hand-held dynamom-
to ensure that the patient is ready to return to preinjury eter. The subjects with knee pain demonstrated 26% to 36%
levels of activity. less knee strength than the control group.
Irish SE, Millward AJ, Wride J, et al: The effect of closed-chain
exercises and open-kinetic chain exercise in muscle activity of
After Return to Sport vastus medialis oblique and vastus lateralis. J Strength Cond
Res 24:1256–1262, 2010.
Continuing Fitness or Research study comparing the effect of two closed-chain exer-
Rehabilitation Exercises cises and one open-chain exercise on VMO and VL activity.
• General conditioning The study had 22 subjects and used surface EMG to compare
VL and VMO activity while performing three different quad-
• Continued LE strength and motion exercise
riceps strengthening exercises. Double-leg squat with isomet-
ric hip adduction was shown to produce the highest VMO : VL
Exercises and Other Techniques for ratio, and the lunge produced the closest idealized ratio of
Prevention of Recurrent Injury VMO : VL. Open-chain knee extension was shown to produce
significantly more VL activation than either of the closed-
• As above chain exercises. (Level II evidence)
Souza RB, Draper CE, Fredericson M, et al: Femur rotation and
patellofemoral joint kinematics: a weightbearing magnetic reso-
Evidence nance imaging analysis. J Orthop Sports Phys Ther 40:277–
285, 2010.
Escamilla RF, Zheng N, Macleod TD, et al: Patellofemoral joint This is a cross-sectional research study involving 15 females
force and stress between a short and long step forward lunge. without knee pain and 15 females with patellofemoral pain.
J Orthop Sports Phys Ther 38:681–690, 2008. The study used weightbearing kinematic magnetic resonance
imaging to compare patellofemoral joint kinematics and
Research study using 18 subjects and 12 repetition max femoral rotation and patella rotation between the groups.
weight while performing forward lunge exercises. The study The females in the patellofemoral group demonstrated both
used EMG, ground reaction force, and kinematic variables significantly greater medial (internal) femoral rotation and
to calculate patellofemoral joint force and stress as a function more lateral tilt than that of the pain-free group. (Level II
of knee angle. Patellofemoral joint force and stress were evidence)
found to be significantly greater when performing a forward
lunge with a short step versus a long step. Lunge with stride Tyler TF, Nicholas SJ, Mullaney MJ, et al: The role of hip
also produced greater force and stress than did the lunge muscle function in the treatment of patellofemoral pain syn-
without a stride. (Level II evidence) drome. Am J Sports Med 34:630–636, 2006.
Thirty-five subjects with patellofemoral pain were evaluated QUESTION 2. Sensorimotor exercises such as balance
and placed in a 6-week treatment program including hip and proprioception should be initiated:
abduction, flexion, and adduction strengthening along with A. Never
iliopsoas and ITB stretching. The subjects that reported the
most improvement demonstrated increased hip flexion
B. During Phase II
strength and iliopsoas and ITB flexibility. (Level II C. During Phase III
evidence) D. During Phase IV
QUESTION 3. Robert’s postrehabilitation of anterome-
dial tibial tubercle transfer should include:
REFERENCES
A. Only open-chain exercises
1. Farr J, Schepsis A, Cole B, et al: Anteromedialization: review and B. Only closed-chain exercises
technique. J Knee Surg 20:120–128, 2007.
2. Ireland ML, Willson JD, Ballantyne BT, et al: Hip strength in females
C. Both A and B
with and without patellofemoral pain. J Orthop Sports Phys Ther D. Neither A nor B
33:671–675, 2003.
3. Tyler TF, Nicholas SJ, Mullaney MJ, et al: The role of hip muscle QUESTION 4. Which manual and soft tissue techniques
function in the treatment of patellofemoral pain syndrome. Am J are permitted in Phase I s/p anteromedial tibial
Sports Med 34:630–636, 2006. tubercle transfer?
4. Escamilla RF, Zheng N, Macleod TD, et al: Patellofemoral joint
force and stress during the wall squat and one-leg squat. Med Sci A. Patella mobilization superiorly and inferiorly
Sports Exerc 41:879–888, 2009. B. Myofascial release
5. Irish SE, Millward AJ, Wride J, et al: The effect of closed-chain C. Soft tissue mobilization
exercises and open-kinetic chain exercise in muscle activity of vastus
medialis oblique and vastus lateralis. J Strength Cond Res 24:1256–
D. All are correct
1262, 2010.
6. Escamilla RF, Zheng N, Macleod TD, et al: Patellofemoral joint QUESTION 5. As long as the patient is pain free, you
force and stress between a short and long step forward lunge. can begin a walk-run program at weeks:
J Orthop Sports Phys Ther 38:681–690, 2008. A. 28 to 32
7. Souza RB, Draper CE, Fredericson M, et al: Femur rotation and
patellofemoral joint kinematics: a weight-bearing magnetic reso- C. 24 to 28
nance imaging analysis. J Orthop Sports Phys Ther 40:277–285, D. 16 to 20
2010. D. 20 to 24
Multiple-Choice Questions Answer Key

QUESTION 1. Correct answer: D (see Phase I:
QUESTION 1. Initial protection of reconstructed knee Protection)
includes the use of bilateral axillary crutches with a
knee immobilizer. Weight-bearing status is TTWB with QUESTION 2. Correct answer: C (see Phase III)
a maxim of:
A. 0 lb exerted through the affected LE QUESTION 3. Correct answer: C (see Phase IV)
B. 5 lb exerted through the affected LE QUESTION 4. Correct answer: D (see Phase I)
C. 10 lb exerted through the affected LE
D. 20 lb exerted through the affected LE QUESTION 5. Correct answer: D (see Phase V)

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EXTENSOR MECHANISM INJURIES

Epidemiology late within the trochlea so that the patella spends a

Pathophysiology Traumatic Factors

FIGURE 28-2. Crossing sign. A,

• Complaints of anterior knee pain carry a long differen-

FIGURE 28-3. TT-TG offset. A, The lateral

Treatment This is a prospective cohort study that identifies risk factors

5. Choose the best indication for MPFL

NONOPERATIVE REHABILITATION OF PATELLAR INSTABILITY

• Modalities such as E-stim and biofeedback can be used

5 Open and Closed Kinetic Chain Exercises

the next stage is contingent upon achieving the goals

Phase I (weeks 0 to 2) Management of Pain and Swelling

Goals • Treatment of pain and swelling continues with cryo-

Phase III (weeks 7 and beyond) REFERENCES

• Surgical management is considered if patellar instabil-

2. When are crutches discontinued after

POSTOPERATIVE REHABILITATION AFTER PROXIMAL

to itself. Excessive medial constraint should be

Details of the Following Treatments that Are

Phase IV: Postoperative Phase V: Postoperative

Details of the Following Treatments That Are

POSTOPERATIVE REHABILITATION AFTER

Indications for Surgical Treatment Brief Summary of Surgical Treatment

needs to be performed often (2 to 3 times a day) to

FIGURE 28-6. Surgical incision. Protection

Factors That May Affect Rehabilitation Management of Pain and Swelling

Phase I: Immediate Postoperative

Stretching and Flexibility Techniques for the Goals

Phase II: Postoperative (weeks 2 to 6) Manual Therapy Techniques

TIMELINE 28-2: Postoperative Rehabilitation After Anteromedial Tibial Tubercle Transfer

• LE stretches are continued, including the hamstring, Goals

Sensorimotor Exercises • Strength MMT 4/5 for quadriceps and hamstrings

Open and Closed Kinetic Chain Exercises

Milestones for Progression to the Next Phase

lunges, great care needs to be placed on educating the

• Add SLS with UE weighted ball toss against rebounder,

Other Therapeutic Exercises

Activation of Primary Muscles Involved in

FIGURE 28-13. A, Partial lunge. B, Full lunge with long A B

FIGURE 28-15. Single-leg balance on DynaDisc with ball toss against

Management of Pain and Swelling

Techniques for Progressive Increase in

Stretching and Flexibility Techniques for the

Functional Exercises • The focus in this phase should be to get UE and LE

Escamilla RF, Zheng N, Macleod TD, et al: Patellofemoral joint

Multiple-Choice Questions Answer Key

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Escamilla RF, Zheng N, Macleod TD, et al: Patellofemoral joint