PATELLAR INSTABILITY AND

MPFL RECONSTRUCTION
By: Alexandria Shaw-Villagrana
 OBJECTIVES:
• Define Patellar Instability
• Causes, Signs & Symptoms
• Patellar Instability Examination
• Surgical & Non-surgical Interventions
• What is the MPFL and how does it effect patellar instability?
• What is MPFL reconstruction?
• Procedural Outcome Data of MPFL reconstruction.
• Rehabilitation of MPFL surgery
WHAT IS PATELLAR INSTABILITY?
• Patellar instability occurs when the
kneecap moves outside of the
trochlear groove.
• 2 types:
• Traumatic patellar dislocation: the
patella gets pushed completely
out of the groove, often the result
of an injury to the knee.
• Chronic patellar Instability: the
patella usually only slides partly out
of the groove known as
subluxation.
 CAUSES AND SIGNS/SYMPTOMS:
Causes: Signs/Symptoms:
• Connective tissue disorder • Pain
• Developmental dysplasia • Swelling
• Stiffness
• Trauma
• Difficulty walking on the affected
• Osseous anatomy of the entire femur (in limb
both torsion and trochlea shape) is usually • Buckling
abnormal and has higher ligamentous • Catching

laxity • Locking sensation

• Less common: deformation in the
• Weak thighs affected knee
• High Q-angle
EXAMINATIONS FOR PATELLAR TRACKING:
• Ask questions about patients’ past health, activities, when the pain started,
and whether it was caused by an injury, overuse, or something else.
• Feel, move, and look at the knee as the patient sits, stands, and walks.
• X-ray and MRI
• Patellar Apprehension Test
 SURGICAL AND NONSURGICAL INTERVENTIONS:
Surgical: Nonsurgical:
• Medial patellofemoral ligament
• Patient education
• Lateral retinaculum release
• Physical therapy
• Femoral trochlea
• Tibial tubercle • Braces
• Femoral antetorsion • Weight bearing reductions
• *Surgical intervention is usually the first
• Pain medication
treatment choice in individuals with
recurrent patella dislocation (Wilkens, • *Conservative treatment is indicated after first

2019). time dislocation (Wilkens, 2019).

 MEDIAL PATELLOFEMORAL LIGAMENT (MPFL):
• The MPFL is a part of the complex network
of soft tissues that stabilize the knee. The
MPFL attaches the inside part of the patella
to the femur.
• The MPFL plays an important role in keeping
the patella on track in the trochlear groove.
• Injury to the MPFL can occur with patellar
dislocation or subluxation.
• When the patella dislocates or subluxation
occurs, soft tissue is damaged as the patella
goes off its normally track and forcibly
comes back into place.
• Due to the patella going off track laterally,
the MPFL can get torn or stretched. The
MPFL can heal on its own, but the ligament
heals in a loosened, lengthened position.
• This causes the patella to become unstable
and increase risk for future dislocation.
 WHAT IS MPFL RECONSTRUCTION?
• MPFL reconstruction is a surgery
in which a new medial
patellofemoral ligament is
created to stabilize the knee
and help protect the joint from
additional damage.
• Graft choice, patellar and
femoral attachments, types of
fixation, and graft tension are
the major focuses of the
surgery.
• Most commonly used graft
choice is the homolateral
gracilis tendon.
 PROCEDURAL OUTCOME DATA OF MPFL RECONSTRUCTION:

• Up to 77% returned to equal sporting level and re-dislocation is described in

0-10% of the patients (Tscholl, 2013).
• MPFL reconstruction techniques, the pooled recurrent patellofemoral
instability rate was estimated to be 0.02 (95% CI) (Wilkens 2019).
• Of the 32 subjects in the MPFL reconstruction group, only 2 knees sustained
recurrent dislocations and none underwent revisions. 72.4% returned to
baseline activity (Puzzitiello, 2019).
 REHABILITATION PROTOCOL:
PHASE I (0-6 weeks):
Quadriceps sets • Four way leg lifts with brace on in supine for hip
strengthening • Ankle pumps • Ankle isotonics with exercise band • 0° – 90° of
knee flexion for passive and active assisted range of motion
PHASE II (6-12 weeks):
Gait drills (begin with pool) • Functional single plane closed chain movements
(begin with pool) • Continued gradual progression of range of motion •
Gradual progress of lower extremity strengthening with precautions to avoid
dynamic valgus or medial knee displacement • Balance and proprioception
exercises
 REHABILITATION PROTOCOL CONT:
PHASE III (12-14 weeks):
Continue range of motion exercises and stationary bike • Closed chain strengthening
begin with single plane progress to multi-plane • Single leg press • Balance and
proprioception exercises: single leg stand, balance board • Hip and core
strengthening • Stretching for patient specific muscle imbalances • Initiate low
amplitude agility drill in the sagittal plane – avoid frontal and transverse initially
because of the potential for dynamic valgus
PHASE IV(14-18 weeks):
Impact control exercises beginning 2 feet to 2 feet, progressing from 1 foot to the
other and then 1 foot to the same foot • Movement control exercises beginning with
low velocity, single plane activities and progressing to higher velocity, multi-plane
activities • Progression to multi-planar agility drills with progressive increase in velocity
and amplitude • Sport/work specific balance and proprioceptive drills • Hip and core
strengthening • Stretching for patient specific muscle imbalances
 REFERENCES:
• Monllau, J. C., Erquicia, J. I., Ibanez, M., Gelber, P. E., Ibanez, F., Masferrer-Pino, A., & Pelfort, X. (2017). Reconstruction of the
Medial Patellofemoral Ligament. Arthrosc Tech, 6(5). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710065/
• Medial patellofemoral Ligament (MPFL) Reconstruction. (n.d.). Retrieved November 17, 2019, from
https://www.hss.edu/conditions_medial-patellofemoral-ligament-reconstruction-mpfl.asp.
• Tscholl, P. M., Koch, P. P., & Fucentese, S. F. (2013). Treatment options for patellofemoral instability in sports
traumatology. Orthopedic Reviews, 5(3), 23. doi: 10.4081/or.2013.e23
• Patellar Instability. (n.d.). Retrieved November 17, 2019, from https://www.hopkinsmedicine.org/health/conditions-and-
diseases/patellar-instability.
• Wilkens, O. E., Hannink, G., & van de Groes, S. A. W. (2019). Recurrent patellofemoral instability rates after MPFL reconstruction
techniques are in the range of instability rates after other soft tissue realignment techniques. Knee Surgery, Sports Traumatology,
Arthroscopy. doi: 10.1007/s00167-019-05656-3
• Forsythe, B., Waterman, B. R., Zuke, W., Puzzitiello, R., Agarwalla, A., Cole, B. J., & Yanke, A. B. (2018). Isolated Medial
Patellofemoral Ligament Repair vs Reconstruction: Rates and Risk Factors for Instability Recurrence in a Young, Active
Population. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 34(12). doi: 10.1016/j.arthro.2018.10.037

• DeFroda, S. F., Hodax, J. D., & Cruz, A. I. (2016). Patellar Instability . The Journal of Pediatrics , 173, 258–258e.1. Retrieved
from https://www.jpeds.com/article/S0022-3476(16)00340-1/pdf
• https://www.uwhealth.org/files/uwhealth/docs/sportsmed/SM-28670_MPFL_Protocol.pdf