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Advancements in Patellofemoral Pain Syndrome & MPFL Reconstruction &

Rehab

Stefanie Bourassa, MSPT, DPT, CSCS, FMSC

Sports Medicine Clinical Program DirectorRehabilitation Director of Bone & Joint Institute of Musculoskeletal

Health at Hartford Hospital

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Provider Disclaimer

• Allied Health Education and the presenter of this webinar do not have any financial or other

associations with the manufacturers of any

products or suppliers of commercial services that

may be discussed or displayed in this

presentation. • There was no commercial support for this

presentation.

• The views expressed in this presentation are the

views and opinions of the presenter.

• Participants must use discretion when using the information contained in this presentation.

Objectives

Review of Anatomy of the knee

Review of biomechanics of the knee

Identify and Palpate MPFL

Understand the biomechanics of MPFL failure

Understand MPFL pathogenesis and reconstruction procedure

Identify and implement a rehabilitation protocol

Identify and evaluate based on the cross diagonal principle

Return the athlete to their sport through specific testing

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The Knee Joint

• Knee Joint

(tibiofemoral joint)

Largest Joint in body

Complex

Primarily hinge joint

(Ginglymus joint)

Patellofemoral Joint

Arthrodial classification

Gliding of patella on femoral condyles

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Bones Enlarged Femoral Condyles articulate with respective med. & lat.

Tibial condyles on the plateau

Tibia bears most of the weight

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Bones Fibula: lateral

Attachment for knee joint structures

Does not articulate on femur or patella

Not considered officially part of the knee joint**

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Bones Patella

Sesmoid

Imbedded in quadriceps and patella tendon

Pulley system for mechanical advantage in knee extension

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Meniscus

Medial meniscus

Larger more open C

Lateral meniscus

Thicker on outside

border

Can slip

Closed C

Both connected by

arcuate fibers

Radicular blood supply

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Meniscus

Functions

Protection of articular cartilage

Joint Stability

Relieve joint incongruity

Increase joint mobility

Load Transmission

In Extension

Lateral: 70%

Medial: 50%

Compressive Load

50% of compression load at 0°

85% at 90° of flexion

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Ligaments/Capsule

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Ligaments: Major

Tibial Collateral Ligament (MCL): Originates on Medial aspect of upper medial femoral condyle and inserts on medial tibialsurface

Fibular Collateral Ligament (LCL): Originates on Lateral femoral condyle close to popliteus origin; inserts on fibular head

Anterior Cruciate Ligament (ACL): Originates PM corner of Femur; inserts via collagen fibers via transitional zone to tibia Resists anterior translation of tibia and rotational forces

Posterior Cruciate Ligament (PCL): Originates AL corner of Femur; inserts posterior tibia Resists posterior translation of tibia and tibial external rotation

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Ligaments: Major

Tibial Collateral Ligament (MCL): Superficial: two separate

tibial attachments

Deep: mensicofemoral: longer proximal to distal

Deep: Meniscotibial: shorter and thicker attached to edge of articular cartilage of medial tibial plateau

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Ligaments: Minor (maybe not so

much)

Medial Patellofemoral Ligament (MPFL)

Posterior Oblique Ligament (POL)

Oblique Popliteal Ligament (OPL)

Popliteofibular ligament (PFL)

Arcuate Ligament (AL)

Fabellofibular ligament (FfL)

Anterolateral Ligament (ALL)

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Ligaments

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Ligaments: Minor

Medial Patellofemoral Ligament (MPFL) O: Medial epicondyle (adductor tubercle

and adductor tendon) as well as MCL

I: Runs transversely deep to the VMO and inserts on superomedial aspect of the patella

F: resists lateral migration of the patella 50-80% of restraining force of lateral patella

dislocation

Most effective between 0°and 30°of flexion

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Ligaments: Minor

Posterior Oblique Ligament (POL) O:adductor tubercle

I:tibia and posterior aspect of the capsule

Inferior arm attaches to the semimembranosus tendon

Superior arm with the posterior capsule and proximal part of oblique popliteal ligament

Femur and anterior to gastrocnemius tubercle

F:provides static resistance to valgus loads as knee moves into full extension

Dynamic stabilizer via attachment of semimembranosus to valgus force as knee moves into flexion

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Ligaments: Minor

Oblique Popliteal Ligament (OPL) O: arises from semimembranosus

tendon and POL

I: lateral head of the gastrocnemius and the arcuate ligament

F: assists with lateral capsular stability

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Ligaments: Minor

Arcuate Ligament (AL)

O: lateral femoral condyle: two heads for the triangular shape

I: traverses over the popliteal tendon and inserts into the fibular head

F: posterolateral stabilizer of the knee

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Ligaments: Minor

Fabellofibular ligament (FfL)

Part of the acruate complex; may be

absent or present depending on size

of ligament itself and arcuate

ligament

O: lateral head of the gastrocnemius

I: fibular styloid process

F: reinforces posterolateral aspect of the capsule

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Ligaments: Minor

Anterolateral Ligament

(ALL) O: lateral femoral

epicondyle; congruous with the LCL

I: Gerdy’s tubercle, fibular head and lateral meniscus

F: anterolateral rotational stability

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Ligaments

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Posterolateral Corner Ligaments

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Anterior Musculature

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Anterior Knee Musculature Three Vasti Muscles originate at proximal femur; insert on

patellar superior pole To Tibial Tuberosity via the patella tendon (ligament)

Tensor Fascia Latae inserts on Gerdy’s Tubercle via IliotibialBand

Sartorius, gracilis, semitendinosus insert Ant. Med. tibialsurface

Iliacus

Iliopsoas24

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Medial Knee musculature Sartorius: Inserts: medial condyle: hip flexion, weak

abductor, external rotator and mild knee flexor

Adductor Longus: Inserts: Medial Femur; Adducts femur

Adductor Magnus: Two portions: adductor and hamstring portion: Inserts: medial femur: adductor portion: adducts, Hamstring portion medially rotates

Gracilis: Inserts: Proximal medial tibia; Adducts the hip; secondary flexion and medial rotation

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PosteriorMusculature

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Posterior Knee Musculature Semimembranosus: inserts PM on medial tibial condyle

Semitendonosis: inserts on medial tibial condyle

Biceps Femoris: inserts primarily on Fibular Head

Popliteus: Originates on lateral aspect of lateral femoral condyle

Triceps Surae: gastronemius, soleus and plantaris Plantaris: arises from the oblique popliteal ligament and inserts along the

lateral head of the gastrocnemius

Gastrocnemius: Medial Head: medial femoral condyle Lateral Head: lateral femoral condyle

Soleus: proximal soleal line of posterior tibia and proximal 1/3 of fibula

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Posterior Hip Musculature Gluteus Maximus: Posterior Femur: Hip extension

Gluteus Medius: Inserts: lesser trochanter: Abducts and Internally Rotates

Gluteus Minimus: Inserts: Lesser trochanter: Abducts and Internally rotates

Pectineus: Pubis to pectinal line: hip flexor and internal rotator

Piriformis: Inserts: greater trochanter; External rotator

Inferior gemelli: Inserts: medial surface of greater trochanter: External rotator

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Palpation

Bony Landmarks: Femoral Epicondyles

(Med./Lat.)

Fibular Head

Patella poles (Sup./Inf./Med./Lat.)

Tibial Tuberosity

Gerdy’s Tubercle

Adductor Tubercle

Musculature Quadriceps (all 4)

Hamstrings and Adductors

Quadriceps Tendon

Patella tendon (some call it a ligament now)

Gastrocnemius

Popliteus

Plantaris

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Palpation

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• Ligaments:• MPFL• MCL• LCL• POL

• Joint Line• Medial • Lateral

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Current Knee Injuries: Layer Approach Layer 1: Osteochondral

Patella, Femoral condyles, tibia, tibial plateau, Osteochondral lesions

Layer 2: Inert Capsule, ACL, MCL, PCL, LCL, MPFL, POL, ALL, Meniscus

Layer 3: Contractile Musculature crossing the knee, musculature crossing the hip

Layer 4: Neuromechanical or Neurokinetic Movement deficits, Tib-fib mechanics, Tib-Femur mechanics,

neurovascular structures, regional mechanoreceptors, kinetic chain

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Treatment Pearls:

Delineate which layer the knee injury is in

Remember tissue healing time

Implement treatment guidelines

Proximal stability before distal mobility

Phases of rehabilitation

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Patellofemoral Pain Syndrome

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Patellofemoral Pain Syndrome

General anterior knee pain

Diagnosis code M22.2X1 (R) M22.2X2 (L)

Affects 15-33% of population; 21-45% adolescent population

Females > Males

Lower Extremity Malalignment Pronation

Genu valgum

Excessive Ext. Tib. Torsion

> 15°Q angle

Excessive hip IR

Patella Alta

Altered kinematics

Over training/under training 34

PFPS: Etiology

Compressive and shearing forces to undersurface of patella

Excessive lateral pressure to patella

Lateral maltracking or displacement of the patella Tight lateral retinacular attachments MPFL sprain Tight/inflexible sartorius, rectus femoris, biceps femoris, vastus lateralis

or ITB Weak medial tracking forces (VMO) vs stronger lateral (vastus lateralis

and ITB) Weak hip abductors and external rotators

Recurrent lateral subluxation MPFL

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PFPS: Pathogenesis

Softening, thinning and fibrillation of the retropatellararticular cartilage

MPFL length tension failure

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PFPS: Clinical Presentation and Evaluation

Subjective Intake is Key H/O subluxation or dislocation

Mechanism of Injury

Where is the pain located

Movie goers sign

Ascend/descend stairs

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PFPS: Pearls of Evaluation ROM

Knee Flexion and extension

Hip flexion, extension, abduction, adduction, ER, IR

Ankle dorsiflexion in standing

MMT Keys:

Hip

Core

Palpation

Special Tests Patellar Tilt Test and Lateral Pull test

POOR interrater and FAIR intrarater reliability

Ober’s Thomas (preferred for even ITB)

J Sign Test

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PFPS: Pearls of Evaluation

Special Tests Cont. Q angle

Craig’s test Ely’s Test McMurray’s for patella tracking Tibial torsion

SLR and Popliteal angle

Gait Barefoot

Shoes

Orthotics

Functional Tests OH Squat

Single Limb Squat

Step downs 39

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PFPS: Pearls of Treatment Manual:

DFM/STM distal ITB, MPFL

Foam Rolling: ART; don’t just roll

Dynamic Stretching

Decrease inflammation

Proximal Stability before distal mobility

Posterior chain strengthening

Prevention of Dynamic valgus

Improve functional movement

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Review Strengthening and Taping

Videos 1 - 8

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MPFL Reconstruction

Patella Dislocation Classification*:

Type Features

Syndromic Genetic Predisposition

Obligatory Dislocates with every episode of knee flexion, self-reduces with extension

Fixed Lateral Remains laterally dislocated, irreducible

Traumatic Initial dislocation due to traumatic event, repeated traumatic dislocations, less energy required

with subsequent episodes

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* Guasden et al. Medial Patellofemoral Reconstruction in Children and Adolescents JBJS Reviews 2015; 3

(10): 2

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Literature Review: Natural History Following Primary Patella Dislocation as Reported in Literature*

Study No. Recurrent

Instability %

Included

Adults?

Risk Factors Identified

Cofield and

Bryan, 1977

48 44 Yes No risk factors identified; 13 patients later underwent

surgical intervention

Hawkins et. al,

1986

27 71 No Patellofemoral malalignment; abnormal patella

configuration

Fithian et al,

2004

110 17 Yes Younger age at initial dislocation; history of

developmental hip dysplasia

Palmu et al,

2008

28 44 Yes Positive family history of recurrent patellofemoral

instability

Sillanpää et al,

2008

21 48 Yes No associated risk factors identified

Lewallen et al,

2013

198 38 No Trochlear dysplasia; immature physes

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*Guasden et al. Medial Patellofemoral Reconstruction in Children and Adolescents JBJS Reviews 2015; 3 (10): 3

Risk Factors for Patella Dislocation Patella alta

Trochlear Dysplasia

Increased Q angle

Increased Tibial tubercle-trochlear groove (TT-TG) distance Index > 0.23 is pathological

Genu valgum

Excessive femoral anteversion

Ligamentous laxity

Excessive Tibial torsion

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MPFL Pathology

Typically avulses from the medial femoral epicondyle

Inconsistent healing capacity which increases risk of reinjurywith recurrent instability

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Indications for MPFL Reconstruction Surgery

Recurrent lateral instability and laxity of the MPFL resulting in incompetent medial restrain

Excessive lateral patella translation

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Contraindications for

MPFL Reconstruction

Surgery

• Patellofemoral arthritis

• Patellofemoral pain

unrelated to instability

• Patellofemoral

malalignment ***

• Requires a tibial turbercle transfer

or osteotomy

• Most Surgeries require both a TTO

and an MPFL reconstruction

• MPFL reconstruction NOT usually

done without a TTO

• Unless within the appropriate Q

angle confirmed on X-ray film

measurements

Surgical Procedure

MPFL Reconstruction with grafting WITH: Tibial tubercle osteotomy/transfer

Lateral retinacular release

MPFL Reconstruction Alone

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Graft Options for MPFL Reconstruction

Semitendonosis tendon graft

Quadriceps tendon graft

Gracilis tendon graft ** Usually combined with semitendonosis tendon

Tibialis anterior tendon graft

Artificial graft

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MPFL Reconstruction Surgical Techniques

3.5 mm titanium anchor

Transosseous 1-mm braided polyester suture

Interference screw fixation

Medial bone bridge

Transpatellar tunnels

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Procedure:

Reference: https://www.youtube.com/watch?v=rmPhjuZ7MFQ

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Procedure: Video of TTO with AMZ and MPFL reconstruction

Reference: https://www.youtube.com/watch?v=dyuiuZvJlTU

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Post-operative rehabilitation of MPFL Reconstruction - **WITHOUT TTO**

Phase I: (weeks 0-2) Full WBAT with crutches

Hinged brace

Locked 0-20° when ambulating

Passive ROM 0-60°

Phase II: (weeks 2-6) Hinged brace 0-90°when ambulating until quad control regained

Full Passive ROM progression

Formal Physical Therapy Initiated

Phase III: (2-3 months) Return to running

Phase IV: (4-6 months) Return to sport

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Post-operative rehabilitation of MPFL Reconstruction - **WITHOUT TTO**

Phase I: (weeks 0-2) Full WBAT with crutches

Hinged brace

Locked 0-20° when ambulating

Passive ROM 0-60°

Phase II: (weeks 2-6) Hinged brace 0-90°when ambulating until quad control regained

Full Passive ROM progression

Formal Physical Therapy Initiated

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Rehabilitation GUIDELINES:

Consult with MD regarding depth of procedure and grafting type

Remember your tissue healing time

Phases of Rehab: Phase I: Pain control and Swelling

Phase II: Increase ROM

Phase III: Increase Strength/Neuromuscular Control/Proprioception

Phase IV: Improve Functional Movement and Strength

Phase V: Return to Play

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Phase I-IV Guidelines

Phase I: GuidelinesRehabilitation Program: Phase I

Phase of

RehabilitationProgram Details

Phase I

Focus: Protect graft site, restore A/PROM, decrease pain & inflammation, normalize gait. Improve Neuromuscular Control

and muscle performance

Precaution: Avoid pivoting, or twisting the knee, limit knee flexion to 90° for the first 4 weeks. Use axillary crutches with

brace locked at 0° during ambulation until adequate quad control is appreciated. Avoid undue pain and stress to surgical

site

Criteria to Advance to Phase II: No signs or symptoms of patella instability, knee ROM 90° or greater (after 4 weeks), full

knee extension, active quadriceps contraction, heel to toe gait pattern with unlocked brace, no assistance of crutches, and

minimal to no joint effusion. Pain less than 5/10

Range of Motion: Stationary bike with seat high, towel slides, ankle pumps

Muscle Performance: NMES with quad sets, Isometrics Hamstrings & Adductors. SLR with brace, 3 way SLR (Abduction,

adduction, extension), Standing Calf raise (single and bilateral), sidelying clams, Double leg bridges, CKC including 1/4

squats and leg press

Proprioception: Single limb balance wearing brace, stable surface

Abdominal Core: Transverse abdominis stabilization exercies

Stretching: Lateral Quad/Iliotibial Band, Hamstrings, gastroc/soleus

Manual Therapy: STM of injured limb: emphasis on quadriceps, hamstrings, lateral quad/ITB tract, PROM grade I/II

superior/inferior patella glides

Modalities: PRN, IFC estim with cryotherapy for swelling management

Home Program: daily pain free A/PROM to 90° knee flexion (4 weeks), basic LE strengthening with no open chained

activity at home59

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Rehabilitation Program: Phase II

Phase of RehabilitationProgram Details

Phase II

Focus: Protect graft site, continue to restore ROM, and gait. Improve muscle performance by progressing CKC

exercises in single planes of motion.

Precaution: Avoid pivoting, or twisting the knee, Overstressing the surgical site, multiplanar movements, CKC

with deep knee flexion angles > 90° and wearing the brace during activity.

Criteria to Advance to Phase III: No signs or symptoms of patella instability, adequate quadriceps strength (i.e.

absense of extensor lag during SLR). Knee ROM 120° or greater, single limb balance 30 seconds or greater,

normal gait pattern with unlocked brace, minimal to no joint effusion

Range of Motion: Phase I activity continued

Muscle Performance: Phase I activity with the progression of CKC exercises: Form Squats, side stepping, 1/4

lunges in frontal and sagittal plane, 4 inch step ups, heel walking and toe walking

Proprioception: Single limb balance on unstable surface

Abdominal Core: Planks, side planks, etc.

Stretching: Phase I stretching continued; add adductors and hip flexors

Cardiovascular: Elliptical and stationary bike; Aquatic therapy if available

Manual Therapy: STM and Joint mobilizations as needed

Modalities: PRN, IFC estim with cryotherapy for swelling management

Home Program: Phase I and II activity with addition of cardiovascular conditioning with the elliptical trainer and

stationary bike

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Rehabilitation Program: Phase III

Phase of RehabilitationProgram Details

Phase III

Focus: Restore FULL joint ROM, muscle performance, improve proprioception and introduce sport

specific/functional movements

Precaution: Avoid overstressing the surgical site, closed chain movements with deep knee flexion angles

(>90°) and post exercise swelling and pain

Criteria to Advance to Phase IV: No signs or symptoms of patella instability, minimal to no joint effusion,

improved quadricep strength to 75% of non-operative leg, normal knee ROM, clearance by surgeon, normal

jogging pattern while wearing brace

Range of Motion: as needed to restore full range of motion

Muscle Performance: Phase II activity with addition of multidirectional CKC exercises and Hamstring

strengthening. Sports specific activity including light jogging patterns (with brace) Non stressing plyometrics,

movement patterns with agility ladder

Proprioception: Single limb balance on BOSU

Abdominal Core: Planks, side planks, etc.

Stretching: Phase I stretching continued; Self myofascial release techniques

Cardiovascular: Elliptical and inclined treadmill, continuation of aquatic therapy

Manual Therapy: STM and Joint mobilizations as needed

Modalities: NONE

Home Program: Phase I and II activity with addition of cardiovascular conditioning with the elliptical trainer

and inclined treadmill

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Rehabilitation Program: Phase IV

Phase of RehabilitationProgram Details

Phase IV

Focus: Returning to full sports activity

Precautions: Pain free activity and avoid post exercise joint effusion

Criteria to return to full activity: No signs or symptoms of patella instability, absence of joint

effusion, normal lower extremity strength, normal neuromuscular control with all sports specific

testing, clearance by surgeon

Range of Motion: Phase I-III as needed

Muscle Performance: Phase I-III as needed, Begin sports specific activity including low level

plyometrics, multidirectional agility drills and circuit training

Abdominal Core: Progressive Core strengthening exercises

Stretching: Phase I-III activities as needed with Dynamic Warm Up

Cardiovascular: Elliptical, stationary bike, progressive jogging

Manual Therapy: STM and Joint mobilizations as needed

Modalities: NONE

Home Program: Phase III-IV activity and addtion of jogging for cardiovascular jogging

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stefanie.bourassa@gmail.com

References

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References cont.

11.Shah JN, Howard JS, Flanigan DC, Brophy RH, Carey JL, Lattermann C. A systematic review of complications and failures associated with medial patellofemoral ligament reconstruction for recurrent patellar dislocation. Am J Sports Med 2012; 40(8): 1916-23.

12.Sillanpää PJ, Salonen E, Pihlajamäki H, Mäenpää HM. Medial patellofemoral ligament avulsion injury at the patella: classification and clinical outcome. Knee Surg Sports Traumatol Arthrosc 2014; 22(10): 2414-8.

13.Singhal R, Rogers S, Charalambous CP. Double-bundle medial patellofemoral ligament reconstruction with hamstring tendon autograft and mediolateral patelar tunnel fixation: A meta- analysis of outcomes and complications. Bone Joint J 2013; 95-B (7): 900-5.

14.Selfe J, Callaghan M, Ritchie E, et al. Targeted interventions for patellofemoral pain syndrome (TIPPS): classification of clinical subgroups. BMJ Open 2013; 3(9):e003795.

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16.Lenschow S, Schliemann B, Gestring J, Herbort M, Schulz M, Koster C. Medial patellofemoral ligament reconstruction: fixation strength of 5 different techniques for graft fixation at the patella. Athroscopy2013. Apr;29(4):766-73. doi: 10.1016/j.arthro.2012.12.004

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