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MPFL Reconstruction
Rehabilitation Concepts in the
Athlete
Russ Paine, PT
UTPhysicians Sportsmedicine
Houston, Texas
Disclosure
• Lite-cure
• mTrigger
Successful Treatment Patellar
Instability
• Big operation
• Re-currentdislocationfailedconservativemng.
• Early hurdles= quadinhibition
• Motion
MPFL Reconstruction
• Gracillis graft to
medial patella
• Fixed to medial
femur
Protocol MPFL
• Locked to 0 for 1 week,
increase ROM 30 degrees
per week
• Quad re-education begins
immediately – isometric
quad setting, G. eliminated
SLR’s
• Progress as tolerated
Quad Inhibition
2
Step One
Don’t Forget Basics
• Q.Sets: 10’
SLR’s: 5’ x 2
Hip ABD: Proximal Control
JOSPT 2003 Ireland
26% Dec. Hip ABD Str. w/anterior knee pain
36% Dec. Hip ER
may lead to pronation
Home Biofeedback
mTrigger
• Records
mVolts of
muscle
activity
• Visual work
intensity goal
• Motivational
Muscle Recruitment
• Order of recruitment –volitional activation begins with small MU progressing to larger MU
• Allows smooth increase in muscle strength = Hennemansize principle
• MU types– Type I or S (slow) smallest
F, slowest contraction
– Type IIa (FR) fast resistant to fatigue larger force fastercontraction times
– Type IIB (FF) fast fatigue largest F fastest contraction
Hip Control Begins
Immediately
• Controllingfemoralposition
• HipABDuctor,G.Max,LateralRotation,
• NWBroutine
Testing Functional Hip
Abductor Strength
• Crossley AJSM 2011
• A- participant demonstratesgood performance
• B- participant demonstratespoor overall and trunkperformance
• C- participant demonstratespoor pelvis and hipperformance
• D- participant demonstratespoor hip and kneeperformance
Step 2
Begin Gradual Loading Exercises
Leg Press Best• MR Leg Press –
supine squat low load
high endurance
activity 60 second
contractions
• Begin with 5Kg
3
Normal P-F Bony
Articulation
• 10 degrees = 1st
articulation
• Propagates frominferior to superior to90 degrees
• 90-135 degrees =medial facet (odd) &lateral, quad tendon
• B=20 C=60 D=90E=120 F=135
Not all leg presses
created the same• Deeper
kneeflexion =incr.PFJRF
• Increasedhip flexion= incr. HSactivity WilkAJSM
Quad EMG – WB & NWB
• Wilk AJSM – knee extension =highest EMG = 25 degrees
• Wilk AJSM – leg press =highest EMG = 85 degrees
• Knee extension = requires highEMG due to lack of patellarheight near extension
• Huberti = Fpt > Fquad 1st 20d.45d Fquad > Fpt = Carefulwith minisquats
Step 3
Dynamic control of Valgus Force
VMO, G. Medius• Apply valgus
force above knee
forcing hip/knee
control
• Add unstable
platform for
stabilization
Control of valgus
• Heel touches: maintain proper hip ABD
position decreases Q-Angle
Step 3
Body Weight Control
Functional Squat
• MR Systems Squat
Control
• Chair Squats 3x20
D & SL
• Speed Squats 20
sec. 5 sets
• Technique = chest
toward ceiling on
way up
4
MPFL Reconstruction
5 mos s/p
• NoSubluxation ordislocationepisodes
• Walk jog 8-10wks
• Difficult earlyrehabilitation
• Near fullrecovery 6mos
When is graft remodeling
complete?
• Scar
remodeling
may have
correlation to
healing
• Clinical pearl
• David Drez
MD
Return To Play Criteria
ROM Symmetry • ≤ 3o deficit for Extension
• ≤ 5o deficit for Flexion
Strength Symmetry• 85% LSI: 60, 180, 300o/sec
Single Leg Squat Symmetry • Y-Balance Anterior Reach
• ≤ 4cm deficit
Dynamic Jump Landing• Landing Error Scoring
System (LESS)
• Good, Fair, Poor
Single Leg Hop Test
• 90% Symmetry of All 4 Tests
Agility • 95% Symmetry Figure of 8
Test (9.5 sec male)
• 95% Symmetry 5-10-5 Pro-Agility
• Deceleration Task
Patient Reported Outcomes• IKDC-2000
• ACL-RSI
• MARX
Deceleration
Return to Function
• Careful
Conclusion
• Turn on quad firing
• 1st 6 weeks arechallenging
• Progressionaccelerates fasterthan ACL
• Resume fullactivities near 6 mos
Advanced Valgus Control
Slide Board
• Maintain core/spine
position
• Don’t allow cg to
move forward
• Control Valgus
5
Continued Body Weight
Ex. – Knee Muscle Force Balance
• Cone touches
• Control Valgus at all
times
Involve the core
• Late stage advanced
strengthening
Avoid functional activities
Until Quad Function Restored
• Altered quad mechanics
= altered P-F mechanics
• Result = pain & quad
inhibition
• Quad = shock absorber
Functional Testing• Tuesday re-
check 7-11AM
• Gathering ofdata
• Over 750ACLpatient’s
Return to Sports 1 year
Factors• Lentz AJSM 2015
• ACL return to sports:fear factor, quadfunction, other
• 1 year s/p ACL 73 pts.46 YRTS 27 NRTS
13 NRTS – other
14 NRTS – Fearconfidence
Quad weakness assoc. with NRTS – Fear, lack of confidence
Chris Powers JOSPT
2003 Case Report
• Controllingfemoralposition
• HipABDuctor,G.Max,LateralRotation,
• NWBroutine
6
Powers: Controlling Hip Internal
Rotation, Knee Adducton• WB routine
• ABD, GMAX,
Lateral rotation
G.Max/Medius
• Extensor, ABD,ER of hip
• Distal control ofknee throughfemoral rotation,adduction
• Combinedhip/quad betterresults NakagawaClin Rehab 2009,Fukada 2010JOSPT
I-T Band Restriction
• O’ber’s Test
• May elicit
pain over
distal
insertion
when
inflamed
Texas Medical Center
Houston
• 21 academic institutions
14 hospitals
• 33.8 million sq. ft.
patient care
• 20K MD’s, scientist,
advanced degreed
• 14 billion annual
economic impact
• 93,500 employees
• 6.0 million patient visits
Disclosures
• mTrigger,
Litecure
Laser
Unstable,
Arthritic, Post-op
• Instability = use muscle
forces hip/knee to improve
stability, use bony anatomy
to promote stability (120-40)
• Arthritic = Avoid ROM
where lesions are present
(30-70) trochlear groove
lesion location
• Post-op PF pain
7
Function - Patella
• Increase moment arm
• Quadriceps = produces
torque
• Patellectomy = 50%
reduction in torque
• Protection from fall
Patellofemoral Rehabilitation
• Most challengingpatients
• Immediate reliefpossible
• Utilize conceptsof biomechanics
• 3 groups:1.unstable2.arthritic3.post-oppain
P-F & Exercise
Steinkamp et al
• Leg press:
PFJRF greatest
where contact
is greatest (60-
90).
• Leg extensions:
PFJRF greatest
where contact
is least (0-30)
P-F Clinical Implication
• P-F leg extension: Pt’s have
pain (0-30) because large F
to minimum area.
• P-F leg press: Pt’s have less
pain (90-60) because able to
distribute forces to
maximum area.
Where are Lesions?
• P-F lesions = 20-45
degrees
• Tibio-femoral =
MFC & MTP 20-70
degrees
• Open Chain avoids
compression T-F
Joint (not all bad!)
• Lewandrowski AJSM
1997
8
Lesion Location
20-40
Osteochondral Allograft
Trochlear groove defect
Osteochondral Graft
Post-op course = NWB 6 wks.,
prolonged atophic course,
Excellent results
PF Pain Following ACL
• Sachs AJSM ‘89
• 19% ACL patients reportedPF pain
• Associated with flexioncontracture
• Quad weakness
• Full hyperextensionShelborne AJSM ’97
• Feller KSSTA ‘01 4 mosno difference PTG, HSAKP
P-F Contact Forces ACL Def.
• Cutting the ACL = increased lateral tilt &
unloading of medial facet
Forces
Articular Cartilage
• Loading of artic.
Cartilage plugs by 1.5 x
BW… 4 sec. on /11 sec.
Off
• 38% increase in GAG
synthesis (cyclic
compression)
• Negative response = 60
sec. On/60 sec. off
• Palmoski JArthRheum
ACL Anterior Knee Pain
Complaints
• Tunnel pain 3-4 mos. s/p
• Fat padimpingement
• Injection,screw orhardwareremoval
• Patellartendonopathy
9
Adrian Peterson NFL Running Back
No Articular Cartilage/Meniscus
Lesions• NFL MVP 2012
• 2,097 yds.
• 6th fastest player toreach 8,000 rushingyards
• 150 yds. 7 games
ACL MCL III 8mos prior to beginof season
No meniscus/articular cartilage injury
Knee Injuries Football
• 13-22% HS football
players have KI
• 54% NFL combine
• 20% NFL combine
were articular
cartilage defects
(MRI)
• Bradley AmJOrtho
2008
NFL Combine MRI Articular
Cartilage Defects
Risk Factors
• Hirshorn Arthroscopy 2010
• BMI > 30.5
• >225 BW
• Linebacker position
NFL ACL injuries return to play
• Shah, AndrewsAJSM 2010
• 63% returned toplay 10.8 mos. Afterreconstruction
• High draft pick (4th
round or higher)
• Greater than 4 yearsof play in NFL
• Greater odds to RTP
Successful Treatment Patellar
Instability
• Big
operation
MPFL Reconstruction
• Gracillis graft to
medial patella
• Fixed to medial
femur
10
MPFL Reconstruction
5 mos s/p
• Subluxation
or dislocation
episodes
• Difficult
early
rehabilitation
• Near full
recovery 6
mos
When is graft remodeling
complete?
• Scar
remodeling
may have
correlation to
healing
• Clinical pearl
• David Drez
MD
Total Knee Replacement
PF Pain• #1 complication
• Resurfacing =“overstuffing”
• (-) resurfacing =chondrolysis AC
• Increased tension onretinacula
• Overstuffing – (underand over) = slackeningof MPFL, stretchingMPFL. Lateral Ret nochanges GhoshKSurgSportsTraumA2009
Articular Cartilage Doesn’t “Hurt”
• Soft tissue overload
• Dye = Equilibrium of
knee forces = balance,
homeostasis
• Restore: normal muscle
forces, normal
flexibility, if needed,
surgical alignment
P-F Imbalance – contact &
compression
• Articular deg. Changes
• Excessive compression =disruption of matrix ofarticular cartilage
• Peri-articular soft tissueirritation
• Scott Dye, M.D. AJSM ‘98= graded patellarcomponents throughprobing
• Results = fat padsuprapatellar pouch
Contact Forces PFJ
11
Shear Forces
Ex. To avoid
• Knee extension
• Plyometric ex’s
• Quick lateral
movements
Goal - Avoid Shear
HOW?
• Increase dynamic support -
Quad/Hamstring strength
• Increase endurance - able to
resist fatigue and maintain
proper mechanics
• Increase/maintain stability =
normal coupled motion =
less shear
P-F Cyclic
compression
exercises• Cycling - proper seat
ht., 90-100 Rpm's,don’t stand on pedals
• Competitivecyclist.com
• MR leg press - allowsbody weight to be reduced
• Pool therapy - load,unload
• EFX ?
• Floyd Landis AVN hipreplacement winner TDeF 2006
Core Strengthening =
Strengthens Kinetic Chain
• LowerAbdominalTrunkflexion/extension using SwissBall
• Hewitt AJSM‘07– Corecontrol may beassoc. withACL tear =pelvic control= kinetic chain= PF control
Flexibility
Evaluation
• Hamstrings whentight = Incr.PFJRF
• Quad Restriction= P. Tendonitis
• Hip flexor tight =Altered pelvicposition
• G-S tightness =incr. pronation
Hip Flexor Stretch
Sidelying
12
Tilt Evaluation
• Lift laterally or press
medially to
determine lateral
soft tissue tightness
• Displace laterally to
grade degree of
laxity
IT-Band & Lateral Tilt
• Deep transverse
retinaculum from ITB
has dense fibrous
attachment to patella
• When restricted, could
produce lateral tilt
• 1995 JOSPT Winslow
correlation ITB ballet
Supportive Approaches• Excessive
pronation =orthotics,reduces Q-angle andlateral tracking
• I-T bandrestriction =may contributeto lateral tilt,glide
• Foam roller =increasedelasticity of I-Tband
• Patellar taping,bracing
Supportive Approaches
• Patellartaping
• P-F bracing,ReactionWeb
• Tapingdoesn’tcorrectlateral tiltWB
• Ho JOSPT2017
Active Internal Tibial Rotation
Improve Q angle
• Aleviates pain
in many
patients
• Can apply
during SAQ,
leg pressing,
stepping
exercises
Loss of Motion
Increased P-F Compression
Why?
• Pressure
necrosis of
articular
cartilage
• Must have
balance to
allow perfusion
of nutrients
13
Kevin Wilk Traveling Fellowship Kevin Wilk Traveling Fellowship
Presented by SPTS and corporate sponsor DJO
Global.
Fellows spend a single week traveling to three
educational sites, spending one to two days each
with noted leaders in our field.
Kevin Wilk Traveling Fellowship
At each site, fellows will be involved in
various activities:
• Observation of the host therapist in
the clinic
• Surgery observation
• Didactic component
• Social activities to expand the
fellows’ professional network
Kevin Wilk Traveling Fellowship
Applications for the fall 2017 class are now being
accepted until July 1!
Fall Fellowship Rotation:
Gary Calabrese, Cleveland, OH
Tim Tyler, New York City
Kevin Wilk, Birmingham, AL
Application available at www.spts.org/education/spts-
traveling-fellowiship
Summary P-F Rehabilitation
• 1st = Quad strengthening
• 2nd = Hip/core control
• 3rd = Flexibility
• 4th = Dynamic P-Fexercise
• Instability 120-40
• Arthritic: low loadcyclic compression
• Knowledge ofBiomechanics =exercise progression
Recommended