Quality and Variability of Online Available Physical Therapy Protocols From Academic Orthopaedic Surgery Programs for Medial Patellofemoral Ligament Reconstruction

Abstract

Background: Unlike the literature on anterior cruciate ligament reconstruction, studies on medial patellofemoral ligament (MPFL) reconstruction lack evidence-based guidelines regarding postoperative rehabilitation. An effective postoperative protocol may contribute greatly to a successful outcome following MPFL reconstruction, yet the quality and variability of these published protocols remain unknown.

Purpose: To assess the quality and variability of MPFL rehabilitation protocols publicly available on the internet and associated with US academic orthopaedic programs.

Study design: Systematic review.

Methods: All available isolated MPFL reconstruction rehabilitation protocols from US academic orthopaedic programs participating in the Electronic Residency Application Service were collected and included in this review. These protocols were evaluated for inclusion of various rehabilitation components, the timing of suggested initiation of these activities, and whether the protocol used evaluation-based guidelines.

Results: A total of 27 protocols were included. Of these, 25 (93%) recommended immediate postoperative bracing. Time to initiation of full weightbearing ranged from 2 to 8 weeks. The most common strengthening exercises endorsed were quadriceps sets (89%), straight-legged raise (85%), and leg press (81%). The most common proprioception exercises endorsed were balance board (41%), single-legged balance (41%), and TheraBand control (33%). The median time suggested to return to play was 17 weeks. No functional test appeared in the majority of the protocols. Of the 27 protocols, 20 (74%) used evaluation-based guidelines.

Conclusion: There is substantial variability in content and timing across rehabilitation protocols following MPFL reconstruction. This lack of clear guidelines can cause confusion among patients, therapists, and surgeons, leading to suboptimal patient outcomes and making it difficult to compare outcomes across the literature.

Keywords: knee; ligaments; physical therapy; rehabilitation.

Figure 1.

Flowchart demonstrating search process. ERAS, Electronic Residency Application Service; MPFL, medial patellofemoral ligament.

Figure 2.

Postoperative adjunct therapy—the majority of protocols recommended immediate postoperative knee bracing. CPM, continuous passive motion; NMES, neuromuscular electrical stimulation; postop, postoperative.

Figure 3.

Range of motion—a minority of protocols recommended that the knee remain locked in full extension at any point after surgery. There was significant variability in target achievement dates for 90°, 110°/120°, and full flexion. Medians are shown as vertical black lines, while ranges are shown as gray bars.

Figure 4.

Weightbearing—no protocol suggested a period of nonweightbearing postoperatively. There was significant variability in target achievement dates for full weightbearing activity; black lines indicate medians, with ranges shown in gray. FWB, full weightbearing; PWB, partial weightbearing.

Figure 5.

Strengthening—quadriceps sets/isometrics, single-legged raise, leg press, and step-up/step-downs were the most common strengthening exercises prescribed. There were wide ranges in recommended initiation time points of the most commonly prescribed strength exercises; black lines indicate medians, with ranges shown in gray. quad, quadriceps; SLR, straight-legged raise.

Figure 6.

Proprioception: balance board was the sole proprioception exercise recommended by >40% of protocols. There was wide variability in the recommended time to initiate various proprioception activities; black lines indicate medians, with ranges shown in gray.

Figure 7.

Functional testing: the single-hop test was the most commonly prescribed functional test. There was wide variability in target achievement dates for all activities surveyed; black lines indicate medians, with ranges shown in gray. Quad, quadriceps.

Figure 8.

Return to activity/sport: there was a wide range of activities recommended across protocols; stationary bike the most commonly suggested. There was significant variability in target achievement dates for all activities surveyed; black lines indicate medians, with ranges shown in gray.