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
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.
The medial patellofemoral ligament (MPFL) is the main passive restraint against lateral patellar translation in the first 30° of flexion. Reconstruction is offered after recurrent dislocations or after a first episode with significant risk factors.
Rehabilitation has two parallel goals: protecting the graft in the early weeks and rebuilding dynamic control of the lower limb, because dynamic valgus and quadriceps/gluteal weakness are key contributors to the dislocation mechanism.
Return to sport after MPFL reconstruction is reported around 85-90%, but return to pre-injury level is lower (about 60-70%); recurrent instability is uncommon (roughly 2-5%) and is more frequent when predisposing anatomical factors (severe trochlear dysplasia, high TT-TG, patella alta) have not been addressed.
Key parameters
- 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
- 0-90° in the first 2 weeks, target 0-120° by 6 weeks, full ROM by 8-12 weeks.
- Open kinetic chain
- Avoid the loaded 0-30° arc in open chain in the early weeks (patellofemoral stress).
- Running
- From month 3-4, with full ROM, no pain or effusion and strength ≥80%.
- Return to sport
- 6-9 months, with no apprehension and controlled dynamic valgus.
Milestones at a glance
- 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
Phases of the pathway
Phase 1 — Graft protection
Weeks 0-2
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
Criteria to progress
- ☐Full active extension without lag
- ☐Pain-free 90° flexion
- ☐Safe gait and decreasing effusion
Phase 2 — ROM and control recovery
Weeks 2-6
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
Criteria to progress
- ☐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
Week 6 to month 4
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
Criteria to progress
- ☐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
Months 4-9
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
Criteria to progress
- ☐Hop tests with LSI ≥90%
- ☐Quadriceps and hamstring strength LSI ≥90%
- ☐Negative patellar apprehension test
- ☐High Kujala score and controlled dynamic valgus on video
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%
- ☐Negative patellar apprehension test and no subjective instability
- ☐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.
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
Guidelines and literature
- Hsu C et al. MPFL reconstruction rehabilitation: current concept review. Int J Sports Phys Ther 2025.
- Platt BN et al. Return to sport after MPFL reconstruction: systematic review and meta-analysis. Am J Sports Med 2022.
- Criterion-based MPFL rehabilitation guidelines (consensus protocols).
Key exercises, step by step
Each exercise belongs to a specific phase: do not anticipate them. Dosage is indicative and must be adapted by your physiotherapist.
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
2. Vastus medialis activation
Weeks 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.
- •Focus on the teardrop muscle above the inner side of the knee.
Dosage: 3 sets of 12, once or twice a day
3. Straight-leg raise
From 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 strengthening
From 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
6. Single-leg balance
From 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-down
Strength 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
8. Progressive plyometrics
Impact 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
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.
MPFL reconstruction after patellar dislocation — Dott. Daniele Priano, Pediatric Orthopaedics · ortopediaevolutiva.com/en/rehabilitation/mpfl-reconstruction · Information document: it does not replace an in-person assessment.
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Email: daniele.priano@ortopediaevolutiva.com