Recovery after medial patellofemoral ligament reconstruction, guided by symptoms and control.
Sport often resumes around 6-9 months after isolated surgery; criteria and associated procedures may change this.
For physiotherapists: adapt exercises, dosage and progression to the injury or procedure, protection, permitted loading and movement; check clinical criteria, not elapsed time alone.
Scope and before starting
This pathway covers isolated MPFL reconstruction after patellar instability. Osteotomy, osteochondral treatment or other associated procedures change loading, brace and motion: the specific operative plan is needed. Rehabilitation restores strength and control without attributing dislocation to one cause.
Loading and brace
Follow operative instructions; increase loading and remove aids when gait is safe and the knee is not becoming irritated.
Motion
Restore extension and flexion gradually without forcing the patella laterally; limits and brace unlocking vary by technique.
Load response
Pain at the front of the knee, joint swelling (effusion) and fear of the kneecap slipping out (apprehension) guide dose alongside strength and control.
Check discharge instructions for permitted loading and knee motion. If permitted loading or movements are missing from your handout, ask for these to be completed before starting.
The physiotherapist increases exercises after checking that pain and swelling do not worsen during or after the session and that the knee remains controlled.
Sport requires strength, confidence and progressive training.
Treatment phases and illustrated exercises
Exercises are shown in their assigned starting phase, with their instructions and precautions. The physiotherapist selects them for the individual plan; the complete protocol is not a prescription to perform them all.
Respect the minimum times and protection required for the procedure. Time alone does not authorise progression: the treating team checks the clinical criteria.
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.
Goals
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.
Preparation plan
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.
Precautions
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.
Criteria checked by the treating team
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 preparation is useful
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.
Home and school preparation
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.
Quadriceps isometric contraction (quad set)
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.
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.
Dose and progression: 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)
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.
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.
Dose and progression: Indicative: 2-3 sets of 8-10 repetitions. To be adapted with the physiotherapist.
Extension recovery with the heel supported
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.
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.
Dose and progression: Indicative: 3-5 minutes, several times a day if well tolerated.
Bridge
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.
Supine, knees bent and feet hip-width apart on the floor.
Lift the pelvis squeezing the glutes, without arching the back, then lower slowly.
Dose and progression: Indicative: 2-3 sets of 10-12 repetitions.
Single-leg balance (only if safe)
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.
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.
Dose and progression: Indicative: 3-5 holds of 20-30 seconds per side.
Stationary bike
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.
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.
Dose and progression: Indicative: 10-20 minutes, as tolerated.
Crutch and weight-bearing training
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.
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.
Dose and progression: At least one training session before admission; repeat until the technique is safe.
Phase 1 · Protection and activation
Early weeks
Goals
Control pain and effusion.
Restore extension and quadriceps activation.
Physiotherapy plan
Gentle motion within permitted limits and thigh contractions; lift the leg only while keeping the knee straight, without it bending during the movement (extension lag).
Walk with prescribed brace and aids.
Precautions
Avoid forced lateral patellar mobilisation and flexion beyond operative limits.
Criteria the treating team checks before progression
Improving active extension and decreasing effusion.
Safe gait with prescribed aids.
Illustrated exercise options
Quadriceps isometric contraction (quad set)
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
Lie on your back with the leg supported and the knee within the authorised extension range.
Tighten the front of the thigh without lifting the leg or forcing the knee. Use a small support under the knee only if demonstrated by your physiotherapist.
Hold briefly and relax. Lifting the heel is neither a target nor proof of full extension.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Controlled straight-leg raise
When motion and muscle activation are permitted and you can keep the knee straight without it sagging; practise first with the physiotherapist.
Lie on your back, position the other leg within its permitted range and keep the exercising leg as instructed; if both sides are treated, respect each side’s limits.
Tighten the thigh and slightly lift the leg while keeping the knee straight; lower it slowly.
If the knee bends during the lift, return to a supported quadriceps contraction. No ankle weights; do not remove a brace without permission.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Phase 2 · Motion and control
After initial protection, often within first 6 weeks
Goals
Improve flexion, gait and knee control.
Physiotherapy plan
Progress ROM and gait according to surgical instructions.
Dynamic quadriceps, hip and trunk strength with partial squats only within cleared loading and range.
Precautions
Elapsed weeks alone do not permit brace unlocking or removal.
Criteria the treating team checks before progression
Controlled gait and improving flexion without increased pain or effusion.
Partial exercises without marked apprehension.
Illustrated exercise options
Side-lying clamshell
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
Lie on your side with hips and knees bent within permitted positioning. Start without a band.
Keep feet together, open the upper knee slightly without rotating the pelvis, then close slowly.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Wall-supported mini-squat
Only after clearance for full weight bearing and strengthening; use the range selected by the physiotherapist.
With your back against the wall as shown, place the feet slightly forward and keep within prescribed loading.
Slide down a short distance within the range set by the physiotherapist, with knees pointing in the same direction as the feet.
Return slowly. Do not copy the illustrated depth if it exceeds your prescribed limit.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Firm-ground balance
After clearance for full weight bearing and single-leg support; practise first with the physiotherapist.
On firm ground with eyes open, slightly lift the other foot while keeping the pelvis level.
Keep one hand on a stable support as illustrated; an adult must be able to assist the child.
Put the free foot down before losing control. Do not add cushions, closed eyes or perturbations.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Phase 3 · Strength and running preparation
After early phase; run only when ready
Goals
Restore strength and single-leg control.
Prepare for straight-line running without reactive pain.
Physiotherapy plan
Progress squats and steps; single-leg balance once gait is safe, according to movement quality.
Begin graded straight-line running only with near-full ROM, normal gait and no reactive effusion; measure quadriceps strength if possible and check a controlled step-down before running.
Precautions
Run only after strength and control assessment; avoid loads that increase pain or apprehension.
Criteria the treating team checks before progression
Full or near-full useful motion without reactive effusion.
Strength and control adequate for running without major compensation.
Illustrated exercise options
Controlled low step-down
After recovering a controlled step-up and receiving clearance for single-leg eccentric work; walking clearance does not automatically permit it.
On a low step, stand on the treated leg and keep a hand on the rail as illustrated.
Slightly bend the knee and lower the free heel towards the floor without dropping down or twisting the pelvis.
Use the free foot and hand support to return as taught. Reduce height and range if movement control deteriorates.
Dose and progression: Use the sets, repetitions or duration, rests and frequency written in your individual handout. Stop before movement control deteriorates; do not choose the dose from the illustration.
Straight-line walk–run progression
Only after running clearance under this protocol and assessment of motion, strength and control. Also respect the protection period for the injury or operation.
On level, even ground, alternate walking with short bouts of easy straight-line jogging according to the physiotherapist’s programme.
Keep an even gait without limping. Begin without sprinting, hills, jumping or direction changes.
Increase one demand at a time. If joint pain, limping or swelling occurs during the work or the next day, stop the progression and report it to the physiotherapist.
Dose and progression: Run/walk intervals, duration and recovery set by the physiotherapist for the procedure, age and response to loading; the phase does not provide an automatic dose.
Phase 4 · Impact and return to sport
During later months, according to function and procedures
Goals
Tolerate jumps, cutting and sport movements.
Physiotherapy plan
After strength and landing checks, progress bilateral jumps to more complex tasks; deceleration and cutting require separate assessment.
From individual to full training before competition.
Precautions
A date, score or 2D video alone does not provide clearance.
Criteria the treating team checks at the end of the pathway
No instability, effusion or limiting apprehension.
Strength, function, movement and full training assessed together.
Illustrated exercise options
Small two-foot forward hops
Only after jump clearance and an on-the-spot landing check by the physiotherapist. The figure shows the forward progression, to introduce with them.
With the physiotherapist, make one small two-foot forward hop on a firm, even surface, as illustrated.
Land on both feet with control and pause before repeating. The physiotherapist selects distance and number of hops; no sideways or single-leg hops without further instruction.
Stop for pain or loss of control and report pain or swelling afterwards.
Dose and progression: Initial attempts and dose selected by the physiotherapist; increase only after checking the subsequent response.
Planned braking and direction changes
After tolerating straight-line running and receiving specific clearance for braking and direction changes. First practise with the physiotherapist; this is not an initial running exercise.
With the physiotherapist, begin with controlled slowing and wide turns at low speed in agreed directions.
Control the trunk, knee and foot. Increase speed and turning angle separately; sharp, reactive or contact movements require further assessment.
Stop for pain, giving way or limping; also report swelling or pain after the session and the next day.
Dose and progression: Intervals, rests and recovery days selected for age, sport and previous level. No independent maximal tests; tolerate full training before competition.
Return to sport / full activity
After isolated reconstruction often around 6-9 months; no paediatric time threshold or test battery is universally validated.
No subjective instability, limiting apprehension or effusion.
Strength and control assessed with age- and sport-appropriate measures.
Full training tolerated with confidence in the knee.
Anatomy and associated procedures change the pathway. Symmetry and scores are useful information, not isolated clearance.
Warning signs: stop and contact the treating team
Fever or a red/draining wound: contact the team promptly.
New dislocation or repeated feeling that the kneecap slips out: stop and seek reassessment.
Increasing anterior pain or effusion: reduce loading and inform the team.
Progressive stiffness or loss of extension: seek review.
New calf pain with swelling: seek urgent medical assessment the same day.
Sudden breathing difficulty or chest pain: seek emergency medical help immediately.
Guidelines and literature
Sources inform the pathway; they do not validate every dose for an individual child.
A framework to personalise with the orthopaedic clinician and physiotherapist, not a replacement for an individual prescription. Respect protection and clinical criteria, not dates alone.
Select the exact phase assigned by the treating team, then choose each prescribed activity. No exercise is selected automatically. The team sets loading, movement, aids, dose and frequency; missing instructions must be completed before use, including by hand.
Browse illustrated exercise options
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.
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.
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.
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.
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.
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.
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.
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
When motion and muscle activation are permitted and you can keep the knee straight without it sagging; practise first with the physiotherapist.
Only when the exercise is cleared in the indicated phase, within prescribed loading and motion.
Only after clearance for full weight bearing and strengthening; use the range selected by the physiotherapist.
After clearance for full weight bearing and single-leg support; practise first with the physiotherapist.
After recovering a controlled step-up and receiving clearance for single-leg eccentric work; walking clearance does not automatically permit it.
Only after running clearance under this protocol and assessment of motion, strength and control. Also respect the protection period for the injury or operation.
Only after jump clearance and an on-the-spot landing check by the physiotherapist. The figure shows the forward progression, to introduce with them.
After tolerating straight-line running and receiving specific clearance for braking and direction changes. First practise with the physiotherapist; this is not an initial running exercise.
Choose the current phase to prepare a printable sheet.
Phase safety summary ·
COMPLETE BEFORE EXERCISING — The treating team must complete the blank instructions, including handwritten entries, before this sheet is used.
Follow the assigned phase and instructions confirmed by the treating team; filling in fields does not authorise exercise.
No exercises assigned. This is a safety summary, not a complete exercise prescription.
Individual instructions for this phase
Loading (how much weight on the leg): ________________________________
Brace and crutches: ________________________________
Procedure and starting conditions
Loading and brace: Follow operative instructions; increase loading and remove aids when gait is safe and the knee is not becoming irritated.
Motion: Restore extension and flexion gradually without forcing the patella laterally; limits and brace unlocking vary by technique.
Load response: Pain at the front of the knee, joint swelling (effusion) and fear of the kneecap slipping out (apprehension) guide dose alongside strength and control.
Advice before starting
Check discharge instructions for permitted loading and knee motion. If permitted loading or movements are missing from your handout, ask for these to be completed before starting.
The physiotherapist increases exercises after checking that pain and swelling do not worsen during or after the session and that the knee remains controlled.
Sport requires strength, confidence and progressive training.
Warning signs: stop and contact the treating team
Fever or a red/draining wound: contact the team promptly.
New dislocation or repeated feeling that the kneecap slips out: stop and seek reassessment.
Increasing anterior pain or effusion: reduce loading and inform the team.
Progressive stiffness or loss of extension: seek review.
New calf pain with swelling: seek urgent medical assessment the same day.
Sudden breathing difficulty or chest pain: seek emergency medical help immediately.
A framework to personalise with the orthopaedic clinician and physiotherapist, not a replacement for an individual prescription. Respect protection and clinical criteria, not dates alone.
A framework to personalise with the orthopaedic clinician and physiotherapist, not a replacement for an individual prescription. Respect protection and clinical criteria, not dates alone.
