1

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