MPFL reconstruction after patellar dislocation
Pathway after medial patellofemoral ligament reconstruction: early graft protection, recovery of quadriceps control and dynamic valgus control, return to sport without apprehension.
Return to sport: typically 6-9 months
This protocol is part of the post-operative pathway and must be adapted to the surgeon’s instructions and to the individual clinical response.
These documents are protocol templates for information and education only: they do not replace the rehabilitation prescription for the individual case. Timing, loading and progressions must always be adapted to the patient, the lesion pattern, the surgical technique used and the clinical course, in collaboration between orthopaedic surgeon, physiotherapist and, where appropriate, physiatrist. Progression is driven by objective criteria, not by the calendar alone.
At a glance
- Brace
- Locked in extension for walking in the first 2 weeks, then progressive weaning.
- Weight bearing
- Weight bearing as tolerated in the brace from the first days, unless bony procedures were combined.
- ROM (indicative windows)
- 0-90° in the first 2 weeks, target 0-120° by about 6 weeks, full ROM by 8-12 weeks. These are indicative references: progression depends on the criteria met and on the surgeon’s instructions.
- Open kinetic chain
- Avoid the loaded 0-30° arc in open chain in the early weeks (patellofemoral stress).
- Running (indicative window)
- Indicatively from month 3-4, subject to criteria: full ROM, no pain or effusion, strength ≥80%.
- Return to sport (indicative window)
- Indicatively 6-9 months, subject to criteria: no subjective instability, dynamic valgus control and confidence in the knee.
- Weeks 0-2Brace in extension, guided flexion 0-60°
- Week 4Flexion 90-120°, progressive brace weaning
- Weeks 6-8Full ROM and normal gait
- Months 3-4Running and advanced strengthening
- Months 6-9Return to sport without apprehension
This protocol refers to isolated MPFL reconstruction. When other procedures are combined — tibial tubercle osteotomy, trochleoplasty, treatment of an osteochondral lesion, lateral soft-tissue lengthening or release — weight bearing, permitted ROM and timelines change substantially, and the surgeon’s specific instructions prevail.
Step by step
Each phase lists the goals, what to do and the exercises for that exact moment: do not anticipate them. Dosage is indicative and must be adapted by your physiotherapist.
Before surgery — Preoperative preparation (prehabilitation)
Indicatively in the weeks before elective surgery, when the knee allows it: duration and need depend on the clinical picture, there is no mandatory minimum.
When it applies
- •Before elective MPFL reconstruction, especially after repeated dislocation episodes.
- •Particularly useful with a still swollen knee, an extension deficit or quadriceps inhibition after the last episode.
- •Carried out with the physiotherapist, with an agreed daily home programme.
Goals before surgery
- •Full extension, or symmetrical to the uninjured knee.
- •Minimal effusion (a "dry" knee).
- •Global quadriceps recovery, with no extension lag.
- •Pelvis and hip (gluteal) control and knee control in single-leg tasks.
- •Education on brace, crutches, allowed weight bearing and the early post-operative phases.
Activities
- •Effusion and pain control (ice, elevation, load management).
- •Practical education on brace, crutches and the goals of the first weeks.
- •Daily home programme, alongside physiotherapy sessions.
Preoperative exercises
Quadriceps isometric contraction (quad set)
- •Lying down, knee straight in a neutral position on the surface; if proprioceptive feedback helps, place a small rolled towel under the knee.
- •Contract the quadriceps pushing the back of the knee toward the surface, hold, then release slowly.
- •Aim for a visible, global quadriceps contraction, without breath holding.
Dosage: Indicative: 10 contractions of 5 seconds, 2-3 times a day. To be adapted with the physiotherapist.
Straight leg raise (only if there is no extension lag)
- •First contract the quadriceps and lock the knee in full extension.
- •Lift the straight leg about 30 cm keeping the knee straight, then lower it slowly.
- •If the knee drops into flexion during the lift (extension lag), stop and work on quad sets first.
Dosage: Indicative: 2-3 sets of 8-10 repetitions. To be adapted with the physiotherapist.
Extension recovery with the heel supported
- •Lying down, rest only the heel on a low support leaving the knee unsupported.
- •Let the knee drop under gravity with the thigh relaxed; a gentle quadriceps contraction can be added.
- •Do not force and do not push abruptly on the knee: extension returns with time and relaxation.
Dosage: Indicative: 3-5 minutes, several times a day if well tolerated.
Bridge
- •Supine, knees bent and feet hip-width apart on the floor.
- •Lift the pelvis squeezing the glutes, without arching the back, then lower slowly.
Dosage: Indicative: 2-3 sets of 10-12 repetitions.
Single-leg balance (only if safe)
- •Standing near a support, load one leg keeping the knee slightly flexed and the pelvis level.
- •Stop if pain, giving-way sensation or instability appear.
Dosage: Indicative: 3-5 holds of 20-30 seconds per side.
Stationary bike
- •To be introduced when range of motion and pain allow: raise the saddle if flexion is still limited.
- •Continuous pedalling at low resistance, pain-free and without increased swelling in the following hours.
Dosage: Indicative: 10-20 minutes, as tolerated.
Crutch and weight-bearing training
- •Try the crutches before surgery, with correct height and the weight-bearing status set by the surgeon.
- •Practise on level ground, stairs and the entrance to your home, with someone assisting.
- •Also practise sitting, standing and moving in the bathroom while respecting the planned loading restrictions.
Dosage: At least one training session before admission; repeat until the technique is safe.
Readiness criteria for surgery
- ☐Full or symmetrical extension and a dry knee, or a stable minimal effusion.
- ☐Effective quadriceps contraction, with no extension lag on straight leg raise.
- ☐Smooth gait, without antalgic limp.
- ☐The young patient and family can use crutches and brace and understand the first post-operative weeks.
When surgery must not be delayed
- •Dislocation with a mobile osteochondral fragment or an intra-articular loose body: treatment must not be postponed to complete preparation.
- •Locked knee or an irreducible patella: immediate assessment.
- •Repeated, closely spaced dislocations: these call for specialist reassessment, especially with osteochondral lesions, marked instability or limitation of daily and sporting activities.
What to prepare at home and school
- •Organise movement at home: clear pathways, remove rugs, keep useful items within reach.
- •Prepare ice, a support for the heel, comfortable clothing and crutches already adjusted.
- •Inform school or the sports club: plan the absence, temporary exemption and gradual return.
- •Agree the first post-operative physiotherapy session in advance.
Preoperative preparation may improve pre-surgical strength and function and support early recovery after reconstruction. It is not a guarantee of the final outcome: the post-operative pathway remains decisive. Dosages and duration are indicative and must be adapted by the physiotherapist.
Phase 1 — Graft protection
Indicative timing: Weeks 0-2
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Pain and effusion control
- •Full extension and quadriceps activation
- •Safe gait in the brace
What to do
- •Quadriceps isometrics, straight leg raise without extension lag
- •Gentle patellar mobilisations (avoid lateral glide)
- •Assisted ROM 0-90°, cryotherapy and compression
Restrictions and precautions
- •No forced lateral patellar mobilisation
- •No flexion beyond 90°
- •Always walk in the brace as prescribed
Exercises for this phase
1. Quadriceps isometric contraction (quad set)From day 1
- •Lie on your back with the leg straight and a rolled towel under the ankle.
- •Push the knee down by tightening the thigh, as if flattening the bed.
- •The heel lifts slightly: that means you are reaching full extension.
Dosage: 10 contractions of 5 seconds, 4-6 times a day
Ready for the next phase when
- ☐Full active extension without lag
- ☐Pain-free 90° flexion
- ☐Safe gait and decreasing effusion
Phase 2 — ROM and control recovery
Indicative timing: Weeks 2-6
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •ROM 0-120°
- •Weaning from the brace
- •Protected-range closed kinetic chain strengthening
What to do
- •Mini squat 0-45-60°, protected-range leg press, glute bridge, low step up
- •Gluteus medius and core strengthening, double-leg proprioception
- •Low-resistance cycling, walking in water
- •Stretching of iliopsoas, quadriceps and posterior chain
Restrictions and precautions
- •Avoid loaded open chain in the 0-30° arc
- •Avoid deep squats and deep lunges
Exercises for this phase
2. Global quadriceps recoveryWeeks 1-6
- •Sitting with a pillow under the slightly bent knee.
- •Extend the knee by pushing the heel forward, keeping the thigh on the pillow.
- •Aim for a full, even contraction of the whole thigh: isolating a single portion of the muscle is not useful.
Dosage: 3 sets of 12, once or twice a day
3. Straight-leg raiseFrom day 1-2
- •Lying on your back, first tighten the thigh until the knee locks straight.
- •Lift the straight leg about 30 cm, hold 3 seconds and lower slowly.
- •If the knee bends while lifting, the quadriceps is not ready yet: go back to quad sets.
Dosage: 3 sets of 10, twice a day
4. Clamshell and gluteal strengtheningFrom week 2
- •Lying on your side, knees bent to 45°, feet together, band above the knees.
- •Open the top knee by rotating the hip, without letting the pelvis roll back.
- •The movement is small: if the pelvis moves, the band is too strong.
Dosage: 3 sets of 15 per side, daily
5. Mini-squat 0-45°From the full weight-bearing phase
- •Standing, feet hip-width apart, weight evenly distributed.
- •Bend the knees to about 45°, keeping the knees aligned over the feet.
- •Rise by pushing through the heels, without letting the knee collapse inwards.
Dosage: 3 sets of 12, 3-4 times a week
Ready for the next phase when
- ☐ROM ≥0-120° without pain
- ☐No effusion
- ☐Pelvic and knee control in single-leg mini squat
Note for the physiotherapist
In patellofemoral pathways, progression is guided by anterior knee pain behaviour: pain increasing over the next 24 hours signals excessive patellofemoral load for the current stage.
Phase 3 — Global strengthening and running
Indicative timing: Week 6 to month 4
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Symmetrical quadriceps, gluteal and core strength
- •Dynamic valgus control
- •Return to straight-line running
What to do
- •Progression squat → split squat → lunge → step down → single leg squat
- •Hip abductor and external rotator strengthening, single-leg proprioception
- •Progressive straight-line running, then wide curves
Exercises for this phase
6. Single-leg balanceFrom the full weight-bearing phase
- •Stand on one leg, knee slightly bent, looking ahead.
- •Progress: eyes open → eyes closed → soft surface → catching a ball.
- •The pelvis must stay level: if it drops on one side, the gluteus medius is weak.
Dosage: 3 x 30 seconds per side, daily
7. Controlled step-downStrength phase (from month 3)
- •Stand on a 15-20 cm step on the operated leg.
- •Lower slowly with the other foot, touching the floor with the heel, over 3 seconds.
- •The standing knee must stay aligned over the foot: if it collapses inwards, lower the step.
Dosage: 3 sets of 8-10 per side, 3 times a week
Ready for the next phase when
- ☐Full ROM, no pain or effusion
- ☐Quadriceps strength LSI ≥80%
- ☐Single leg squat without dynamic valgus and without apprehension
Phase 4 — Plyometrics, agility and return to sport
Indicative timing: Months 4-9
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Controlled jumping, landing and cutting
- •Sport-specific skills
- •No apprehension
What to do
- •Progressive plyometrics with video feedback on landing alignment
- •Progressive agility, deceleration and change of direction
- •Sport-specific training and graded team reintegration
Exercises for this phase
8. Progressive plyometricsImpact phase
- •Start with two-foot hops on the spot, landing softly with bent knees.
- •Progress to front-back and lateral hops, then single-leg.
- •Landings must be silent: noise means insufficient shock absorption.
Dosage: 2-3 sets of 10-20 contacts, 2-3 times a week
Ready for the next phase when
- ☐Controlled jumping and landing, without dynamic valgus collapse
- ☐No instability episodes or apprehension during the exercises
- ☐Sport-specific training tolerated progressively
- ☐The instrumented criteria for clearance are listed in the return-to-sport section
If symptoms appear after a progression
If persistent pain, effusion or swelling, or loss of movement appears after moving to a new phase or increasing load, temporarily reduce load and volume and have the situation reassessed by the surgeon or physiotherapist before progressing again. This document is informative for families and physiotherapists and does not replace individual clinical assessment.
Return to sport / full activity
6-9 months; in isolated low-risk cases some protocols allow 4-6 months, but consensus advises caution.
- ☐Hop tests with LSI ≥90%
- ☐Quadriceps and hamstring strength LSI ≥90%
- ☐Overall clinical assessment of patellofemoral stability: no subjective instability, confidence in the knee and no reported apprehension during sporting movements (the apprehension test is one element, not a binary green light)
- ☐High Kujala score
- ☐Documented dynamic valgus control (2D video in single leg squat and drop jump)
When uncorrected predisposing anatomical factors coexist (severe trochlear dysplasia, high TT-TG, patella alta), recurrence risk is higher and return to high-risk sport must be discussed case by case. The Limb Symmetry Index has known limitations: on its own it is not sufficient, because the uninjured side may also be deconditioned; it should be combined with absolute strength values, movement quality and sport-specific demands.
Red flags: stop and contact us
- •Apprehension or the feeling that the kneecap is "about to slip out" during exercises
- •New dislocation or subluxation episode: stop and contact us immediately
- •Persistent and worsening anterior knee pain
- •Recurrent effusion after sessions
- •Loss of flexion or progressive stiffness
- •Fever, redness or discharge from the surgical wound
Written and reviewed by Dott. Daniele Priano, Paediatric Orthopaedics. Last review: August 2026.
Timings are indicative: progression depends on clinical and functional criteria and on the surgeon’s indications.
Frequent questions
Can the kneecap dislocate again?
MPFL reconstruction greatly reduces the risk but does not eliminate it, especially with predisposing factors such as trochlear dysplasia, patella alta or valgus alignment. Gluteal work, dynamic valgus control and quadriceps strength are integral to prevention.
Why so many hip exercises if the problem is the knee?
Because the patella glides in a groove that moves with the femur: if the hip rotates inwards, the groove shifts and the patella tends to move laterally. Controlling the hip stabilises the patella from above.
Is swelling in the evening normal?
Mild evening swelling in the first weeks is common. It becomes a warning sign when it increases day by day, appears after every session, or does not settle within 24-48 hours with ice and elevation: in that case the weekly load is excessive and should be reduced by one level.
Can I do physiotherapy only once a week?
The physiotherapy session is for setting up, correcting and progressing the programme. The result, however, depends on the exercises performed at home every day: a short daily home programme is worth more than an isolated weekly session.
In-depth content (full introduction, technique comparison, FAQ, references) at ortopediaevolutiva.com/en/rehabilitation/mpfl-reconstruction
MPFL reconstruction after patellar dislocation — Dott. Daniele Priano, Pediatric Orthopaedics · Information document: it does not replace an in-person assessment.
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Email: daniele.priano@ortopediaevolutiva.com