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The Physician and Sportsmedicine
ISSN: 0091-3847 (Print) 2326-3660 (Online) Journal homepage: http://www.tandfonline.com/loi/ipsm20
Rehabilitation variability following medial
patellofemoral ligament reconstruction
Harry M. Lightsey, Margaret L. Wright, David P. Trofa, Charles A. Popkin &
Lauren H. Redler
To cite this article: Harry M. Lightsey, Margaret L. Wright, David P. Trofa, Charles A. Popkin
& Lauren H. Redler (2018): Rehabilitation variability following medial patellofemoral ligament
reconstruction, The Physician and Sportsmedicine, DOI: 10.1080/00913847.2018.1487240
To link to this article: https://doi.org/10.1080/00913847.2018.1487240
Accepted author version posted online: 09
Jun 2018.
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Accepted Manuscript
Publisher: Taylor & Francis
Journal: The Physician and Sportsmedicine
DOI: 10.1080/00913847.2018.1487240
Rehabilitation variability following medial patellofemoral ligament reconstruction
Harry M. Lightsey1, Margaret L. Wright1, David P. Trofa1, Charles A. Popkin1, Lauren H. Redler1
1Department of Orthopedic Surgery, New York Presbyterian/Columbia University Medical
Center, New York, USA
Corresponding author
Lauren H. Redler
622 West 168th St., PH11-Center Wing, New York, NY 10032
Email: lr2505@cumc.columbia.edu
Transparency statement
Declaration of funding
This manuscript was not funded.
Declaration of financial/other interests
The authors have disclosed that they have no significant relationships with or financial interests
in any commercial companies related to this study or article. Peer reviewers on this manuscript
have received an honorarium from The Physician and Sportsmedicine for their review work, but
have no other relevant financial relationships to disclose.
Acknowledgements
None reported.
Accepted Manuscript
Abstract
Background: Medial patellofemoral ligament (MPFL) reconstruction is an increasingly utilized
surgical option for recurrent patellar instability. Recent studies have highlighted the potential
benefits of accelerated functional rehabilitation; however, no validated MPFL rehabilitation
guidelines currently exist.
Objective: To assess the variability of MPFL reconstruction rehabilitation protocols published
online by academic orthopaedic programs.
Methods: Online MPFL rehabilitation protocols from U.S. teaching orthopaedic programs were
reviewed. A comprehensive scoring rubric was developed to assess each protocol for both the
presence of various rehabilitation components and timing of their introduction.
Results: Thirty-one protocols (20%) were identified from 155 U.S. academic orthopaedic
programs. Thirty protocols (97%) recommended immediate postoperative knee bracing. Twenty
protocols (65%) allowed for weightbearing as tolerated using crutches immediately
postoperatively, while seven protocols (23%) recommended partial weightbearing and four
protocols (13%) recommended toe-touch weightbearing. For those protocols advising partial
and toe-touch weightbearing, advancement to full weightbearing was achieved at averages of
4.7 (range, 3-8) weeks and 6.3 (range, 6-7) weeks, respectively. There was considerable variation
in range of motion goals; however, most protocols (97%) recommended achieving 90 degrees of
knee flexion at an average of 1.4 (range, 0-6) weeks. Significant diversity was found in the
inclusion and timing of strengthening, stretching, proprioception, and basic cardiovascular
exercises. Twenty-five protocols (81%) recommended return to training after completing certain
athletic criteria.
Conclusions: A minority of U.S. teaching orthopaedic institutions publish MPFL reconstruction
rehabilitation protocols online. Furthermore, there is a high degree of variability in both the
composition and timing of rehabilitation modalities across these protocols.
Keywords: patellofemoral joint, rehabilitation, joint instability, knee dislocations
Accepted Manuscript
Introduction
Patellar instability is a common clinical problem affecting young female athletes,11, 28, 33 with
an incidence of approximately 29:100,000 person-years in the 10-17 year age group.31 While
first-time, acute patellar dislocation is traditionally managed nonoperatively,7 recurrent
dislocation occurs in as many as 44% (range, 15-44%) of patients, with a higher frequency
among athletes.5, 16, 17 Recurrent patellar instability can have a significant negative impact on a
patient’s quality of life in athletic, occupational, and social domains.28 For these patients,
reconstruction of the medial patellofemoral ligament (MPFL) restores the primary soft tissue
stabilizer against lateral displacement of the patella and has been shown to return patellar
tracking to near normal.14, 26 Following surgery, rehabilitation that is mindful of both the soft
tissue reconstruction yet progressive in promoting early functional recovery is critical in the
effort to achieve pre-injury levels of activity.19, 20, 33
Currently, no validated MPFL rehabilitation protocol exists. While some studies have
outlined MPFL-specific postoperative guidelines,19, 20, 23, 33 the majority of physical therapy
programs in use clinically are adaptations of anterior cruciate ligament (ACL) reconstruction
protocols.20 The absence of a standard protocol is due to a paucity of research intent on
determining the clinically effective elements of MPFL rehabilitation. While the number of
studies with this objective has increased in recent years, different conclusions have been drawn
with regard to what should be considered best practice. Some studies advocate a traditional
approach that is similar to ACL reconstruction protocols in emphasizing the importance of early
protection of the postsurgical knee.20, 33 Conversely, some investigators argue for early dynamic
functional rehabilitation to expedite return to activity and sport, as well as to avoid
postoperative knee stiffness.19
In this study, online MPFL reconstruction rehabilitation protocols from academic
orthopaedic institutions were reviewed with aims of evaluating (1) protocol variability with
regard to the inclusion and timing of physical therapy components and (2) protocol availability
for patients utilizing the Internet to search for rehabilitation information.
Methods
This study reviewed publicly available rehabilitation protocols from academic orthopaedic
surgery programs in the United States identified from the Electronic Residency Application
Service (ERAS). A general web-based search was performed using the search term
“[Program/affiliate hospital/affiliate medical school name] MPFL reconstruction rehabilitation
protocol” to select official rehabilitation protocols. Exclusion criteria consisted of protocols
designed for pediatric patients, those involving concomitant procedures, and those lacking
sufficient detail such as commencement time points for rehabilitation components.
A custom scoring rubric was designed after a comprehensive review of available protocols
and a literature review regarding components of MPFL reconstruction rehabilitation. The rubric
consisted of specific sections for included metrics; binary coding was used to assess the
inclusion of specific rehabilitation components while numerical coding was used to evaluate the
range of commencement dates. Protocols were scored by the primary author and confirmed
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independently by the co-authors. The following broad categories were defined in the rubric:
postoperative adjunctive therapies, range of motion, weightbearing, strengthening, stretching,
proprioception, return to basic activity, and return to athletic activity (Table 1). Each protocol
was analyzed for specific modalities within the above categories, scored accordingly, and the
data was synthesized and formatted into figures using Excel. When analyzing commencement
date ranges, averages were calculated in accordance with previous work focused on examining
rehabilitation protocol variability.18
Results
One hundred and fifty-five ERAS orthopaedic programs were included for review; 28 (18%)
provided online rehabilitation protocols that met eligibility criteria. As some programs published
more than one protocol, 31 protocols were analyzed in total.
Postoperative Adjunctive Therapy
Five types of postoperative adjunctive therapies were assessed (Fig. 1): bracing (both
immediate postoperative bracing with range of motion (ROM) settings as well as postrecovery
functional bracing), neuromuscular electric stimulation (NMES), cryotherapy, continuous passive
motion (CPM), and patellofemoral taping. The majority of protocols (97%) recommended
immediate postoperative bracing; 25 of these protocols (81%) advised locking the brace in full
extension. The average time for brace discontinuation was 5.7 (range, 2-9) weeks. Only four
protocols (13%) reported guidelines for using a postrecovery functional brace. Over half of all
protocols (20 of 31; 65%) employed NMES as an adjunct to quadriceps strengthening exercises.
Thirteen protocols (41%) recommended cryotherapy and eight protocols (26%) prescribed CPM
use. Three protocols (10%) recommended patellofemoral taping as needed throughout the
course of rehabilitation.
Range of Motion and Weightbearing
There was considerable variability in both the inclusion and timing of specific ROM goals
(Fig. 2). Thirty protocols (97%) set goals of 90 degrees of knee flexion, while only 14 protocols
(45%) set goals for 120 degrees of flexion and 17 protocols (55%) set goals for full flexion (>135
degrees).
Regarding postoperative weightbearing, a majority of protocols (65%) allowed for
immediate weightbearing as tolerated using crutches. The average time to discontinuation of
crutches occurred at 1.9 (range, 1-6) weeks. Seven protocols (23%) recommended routine
partial weightbearing and four protocols (13%) advised toe-touch weightbearing immediately
postoperatively. For those protocols recommending immediate partial weightbearing, there was
a 5-week range (3 to 8 weeks postoperatively) with a mean of 4.7 weeks in the stated goal for
achieving full weightbearing. The average time to full weightbearing for protocols advising toe-
touch weightbearing occurred at an average of 6.3 (range, 6-7) weeks postoperatively.
Strengthening
Twelve basic strengthening exercises were assessed in the rubric for MPFL rehabilitation
protocols (Table 1). Five of the 12 exercises appeared in greater than 50% of the protocols (Fig.
3A). Among the most common strengthening exercises, straight-leg raises (SLR) and quadriceps
sets were routinely prescribed within the first postoperative week. However, wide variation was
found with regard to commencement dates for most of the remaining exercises (Fig. 3B). The
highest variability in start dates existed for single-leg squats (15 week range from the earliest
recommended start date), as well as hamstring curls and leg press (each with a 14 week range
from an earliest allowable start date of two weeks).
Stretching and Proprioception
Five different stretching exercises for MPFL physical therapy protocols were assessed (Table
1). Two of the five appeared in greater than 50% of the protocols (Fig. 4A). Patellar mobilization
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tended to be the earliest recommended stretching exercise at an average 1.3 (range, 0-7) weeks
(Fig. 5A). All protocols recommending patellar mobilization cautioned against lateral patella
movement.
With regard to proprioception, 90% of protocols recommended general proprioceptive
activities. However, none of the seven specific proprioceptive exercises appeared in greater
than 50% of the protocols (Fig. 4B). As with strengthening exercises, wide variation was found
with regard to the earliest commencement dates of the most common proprioceptive exercises
(Fig. 5B).
Return to Basic Activity
Regarding return to basic cardiovascular activities, stationary biking with a high seat and low
resistance and jogging were the most commonly recommended activities, advised by 90% and
84% of protocols, respectively (Fig. 6A). Stationary biking was also the earliest activity initiated
amongst the protocols with an average start date of 4.1 (range, 0-7) weeks (Fig. 6B). In total, 11
specific cardiovascular activities were evaluated in the rubric for MPFL protocols, five of which
were recommended by more than 50% of protocols.
Return to Athletic Activity
The most common athletic activities included plyometrics and “sport-specific” drills,
recommended by 23 protocols (74%) and 24 protocols (77%), respectively (Fig. 7A). Agility
exercises, as well as cutting/pivoting drills, were also recommended by greater than 50% of
protocols at averages of 14.1 and 14.5 weeks, respectively. While these activities were
commonly mentioned in protocols, they were rarely described in detail with regard to the
specific exercises to be performed (Fig. 7A). Agility training had the widest range of
recommended commencement dates; however, the mean start times for all athletic activities
fell between 13 and 16 weeks postoperatively (Fig. 7B).
Twenty-five protocols (81%) specifically mentioned return to training as a goal for MPFL
reconstruction rehabilitation at an average of 17.6 (range, 12-26) weeks postoperatively.
However, only 12 protocols (39%) provided criteria for return to training, seven of which (23%)
specifically mentioned single leg hop tests and isokinetic quadriceps strength measurements.
Only one protocol explicitly mentioned return to competition at 26 weeks postoperatively.
Discussion
The results of this study reveal that a minority of ERAS orthopaedic programs publish MPFL
rehabilitation protocols online. Across these protocols, there is significant variability with regard
to both the inclusion of physical therapy components and the timing of rehabilitation
milestones. These findings point to the lack of a validated standard of care and represent an
opportunity to improve patient care through increased protocol standardization. Furthermore,
as patients increasingly utilize the Internet to research healthcare information,21 readily
accessible, patient-directed online rehabilitation protocols are important to ensure safe and
effective care.
Rehabilitation following lateral patellar dislocation has been the subject of research for
several decades.5, 7 For those patients suffering from recurrent patellar instability after
nonoperative management, MPFL reconstruction has become an increasingly employed surgical
option. However, concomitant studies devoted to understanding MPFL postoperative
rehabilitation are lacking. Presently, most MPFL physical therapy protocols are extrapolated
from ACL reconstruction protocols and are heavily influenced by variable surgeon preferences.20
Within the past several years, a combined research effort by physicians and physical therapists
has pushed for a validated standard of care protocol.19, 20, 33 Interestingly, recent studies in this
effort have reached varying conclusions regarding fundamental components of rehabilitation,
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including knee immobilization, early range of motion, and weightbearing. With this in mind, the
authors felt it important to evaluate accredited online protocols in an effort to examine this
variability and to encourage outcome-based studies through which clinically beneficial
modalities can be identified and recommended. In this way, an evidence-based, standardized
protocol could be proposed to serve as both a guide to the clinical surgeon as well as a patient-
directed resource.
Knee Immobilization
Knee immobilization post-MPFL reconstruction is a contentious subject centering on early
graft protection versus the risk of postoperative stiffness. In our study, 97% of protocols advised
immediate postoperative bracing and 81% recommended locking the brace in full extension.
Notably, surgeon preference with respect to postoperative knee immobilization is highly
variable with descriptions in the literature ranging from a one-week compressive bandage to a
Bledsoe brace locked in full extension for the first six weeks.1, 9 In 2007, Smith et al.29 reviewed
eight case series consisting of 174 patients having undergone MPFL reconstruction and found no
significant difference in clinical or radiological outcomes between studies using and those not
using knee orthoses. Accordingly, the most progressive studies have proposed not using any
form of knee immobilization throughout the recovery process.19
Early Range of Motion
Knee stiffness and flexion contractures are two common and troubling complications
following knee surgery. This is true following MPFL reconstruction in particular, given the risk of
graft malposition and tethering the joint.13, 19, 20 Regaining full extension is a critical
postoperative goal with drastic implications on functional outcomes. In our study, only nine of
31 protocols (29%) provided a goal date for full extension at an average of 1.0 (range, 0-5) week.
Indeed, all ROM milestones across online rehabilitation protocols were underreported with the
exception of 90 degrees knee flexion goal. However, from the few protocols providing detailed
timeframes, a progressive approach toward achieving early full ROM predominated. For
example, the average times to achieve 120 degrees flexion and full (>135°) flexion were 3.8
(range, 0-7) and 6.8 (range, 2-12) weeks, respectively. This is in contrast to a recent case series
where the same ROM milestones were reached at averages of 8.8 and 12.4 weeks.33
Ultimately, the risk of postoperative stiffness secondary to immobilization must be weighed
against the potential for soft tissue injury secondary to early functional motion. Biomechanical
studies have shown that the MPFL experiences maximal loads near full extension and during
early flexion.13 With this in mind, and given the increased graft tensile strengths compared to
the native MPFL, it stands that if the graft is positioned correctly it should be capable of
tolerating increases in knee flexion without failing.19
Weightbearing Restrictions
Restrictions on weightbearing status following MPFL reconstruction are thought to protect
against soft tissue injury; however, as Fithian et al.12 note, the reconstruction itself is not
affected by axial loading. They note that as long as rotation of the knee is prohibited, early full
weightbearing is permissible. Importantly, delayed weightbearing can have negative
implications such as joint stiffness, muscle atrophy, kinesiophobia, fear-avoidance, and impaired
quality of life.19, 20
None of the online protocols included in our study were so progressive in recommending
immediate full weightbearing. The majority of protocols (65%) allowed for immediate
weightbearing as tolerated with crutches. The average time to crutch discontinuation was 1.9
(range, 1-6) weeks. Furthermore, several protocols advised immediate partial and toe-touch
weightbearing with progression to full weightbearing at averages of 4.7 weeks and 6.3 weeks,
respectively.
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Weightbearing limitations in the scientific literature are also variable.20 While this disparity
may be partially explained by differences in surgeon preference and surgical technique, a wide
range of weightbearing restrictions still exists for technically similar operations.6, 25 In a recent
case series by Vitale et al.33 of seven patients who underwent MPFL reconstruction with
semitendinosus autograft, weightbearing as tolerated with the use of an assistive device was
permitted between two and eight weeks. Full weightbearing was achieved at an average of 5.9
weeks. More recently, Manske et al.19 have proposed immediate weightbearing as tolerated
with progression to full weightbearing within the first two weeks.
Strengthening Exercises
Quadriceps strengthening following knee surgery is critical to achieve muscle reactivation
and avoid inhibition and dysfunction.12 Recent research has validated the use of neuromuscular
electric stimulation (NMES) for reducing loss of strength and gait abnormalities following ACL
reconstruction.19 Given the potential for similar neuromuscular deficits following ACL and MPFL
surgeries, many physicians and physical therapists recommend NMES following MPFL
reconstruction. Studies have shown that coupling NMES with active therapeutic exercises, such
as quadriceps sets and straight leg raise, is most effective.30 More recent investigations have
shown improved functional outcomes with increased strength gains of the quadriceps when
using NMES following ACL reconstruction.24 In this study, quadriceps sets and straight leg raise
were the most common strengthening exercises and were routinely prescribed within the first
operative week. A majority of protocols (65%) recommended NMES as an adjunctive therapy to
these exercises.
The ability to preferentially strengthen the vastus medialis oblique (VMO) has been debated
in the context of recurrent patellar dislocation and MPFL rehabilitation.27, 28, 33 In 2009, Smith et
al.27 systematically reviewed 20 studies with 387 patients and concluded that neither lower
extremity orientation nor co-contraction preferentially enhanced VMO activity. More recently,
Vitale et al.,33 citing anatomic considerations, encouraged adductor strengthening in an effort to
recruit the VMO and increase dynamic medial stability of the patella. Interestingly, this debate
within the scientific literature has not resulted in widespread variability of online rehabilitation
protocols. Only two protocols included in this study explicitly recommended VMO strengthening
by performing single leg raises with external hip rotation.
Advanced strengthening exercises are introduced after patients achieve full weightbearing
and can tolerate activity with minimal pain and swelling. In a recent review of best practice
guidelines in the conservative management of patellofemoral pain (PFP), Barton et al.3 highlight
the importance of quadriceps strengthening. They also note growing evidence and expert
support for gluteal strengthening and core stability/trunk strengthening as components of PFP
rehabilitation. Such exercises have been stratified by electromyographic (EMG) studies
according to maximal volitional contraction.8 Manske et al.19 proposed using this system to
inform MPFL rehabilitation protocols of high-yield strengthening exercises. Notably, only two of
the top 10 exercises, lunges and single-leg squat for gluteus medius and maximus, ranked by
mean EMG were commonly recommended by the online protocols reviewed in this study.
Functional Performance Testing
Recent studies have shown that successful MPFL reconstruction followed by rigorous
physical therapy have the potential to enable patients to return to pre-injury levels of activity
and sport.19, 33 In the final stages of rehabilitation, patients should demonstrate competence and
confidence across a range of functional and athletic activities prior to return to training. Recent
scientific literature strongly supports the use of functional performance tests as valuable
objective measures for evaluating lower extremity function and gauging confidence in the
surgically repaired knee.10, 15, 19, 20 Maximum voluntary isometric contraction of the quadriceps
Accepted Manuscript
and hamstrings as a means of measuring and monitoring muscle strength has also been
described in assessing readiness for return to training.20 Functional testing was rarely
recommended by the protocols included in this study; only 23% of protocols mentioned hopping
tests or isometric strength measurements as criteria for progression in return to training.
Rehabilitation Protocol Standardization
In addition to the effort to incorporate evidence-based modalities and clinically effective
rehabilitation tools, online protocols can be improved by increased standardization of physical
therapy progression. Process standardization has been shown to result in improved clinical
outcomes and more efficient use of resources in total joint replacement.4, 32 In this study,
substantial variability was found across online academic protocols with regard to both the
inclusion of specific physical therapy components and the timing of when such components
were introduced. Such discrepancies between protocols are the result of a lack of professional
consensus regarding the optimal postoperative rehabilitation regimen. Furthermore, in addition
to the wide start ranges observed for certain components, many protocols lacked patient-
directed instructions and clear progression criteria for exercises and activities. Ultimately, this
variability and lack of clarity has the potential to result in both patient and caretaker confusion
and subsequent worse functional outcomes. Standardization of high-quality protocols would
help ensure a more navigable and safe recovery course for patients, with the understanding that
specific patient and surgical circumstances may necessitate occasional changes to the protocol.
Online Protocol Availability
Similar to ACL reconstruction rehabilitation,18 a minority of academic orthopaedic programs
publish MPFL protocols online. It is common practice for surgeons to communicate
rehabilitation protocols directly to patients or to physical therapists. However, patients are
increasingly utilizing the Internet to independently access healthcare and rehabilitation
information.21 Recently, Amante et al.2 described the rise in healthcare-related Internet usage
and emphasized the importance of accurate and reliable online patient-directed resources.
Rehabilitation resources would be valuable to patients from initial injury to the end of recovery.
In the preoperative period, patients could gain a more complete understanding of the recovery
process. During the postoperative period, patients could independently use protocols in the
home setting or could consult and/or supplement existing protocols. In these ways, increased
protocol availability may lead to increased patient participation in their own rehabilitation
course. With this in mind, and given the results of the current study, it is important to increase
the online availability of clinically effective rehabilitation protocols.
Study Limitations
There are several limitations to the present study. First, although 155 total academic
programs were considered, only 31 programs provided protocols that satisfied eligibility criteria.
Based on our initial web searches, it was apparent that this number represents a minority of all
online MPFL reconstruction rehabilitation protocols. Many individual physicians and private
practice groups have personalized websites where their particular protocols can be found.
However, our methodology followed that of similar rehabilitation studies and was used in order
to best illustrate the current state of practice from a distinct group of institutions most likely to
be involved in research related to rehabilitation guidelines.18 Second, it is common practice for
orthopaedic surgeons to give their protocols directly to patients or to physical therapists. Such
protocols are more likely to be personalized, incorporating preoperative considerations and
intraoperative decisions. Third, MPFL reconstruction is often performed with concomitant
procedures that could significantly alter postoperative rehabilitation. Of note, while
rehabilitation protocols in this study were limited to isolated MPFL reconstruction, the protocols
themselves rarely specified graft selection and surgical technique. However, a recent systematic
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review found no significant difference between autograft and allograft or synthetic grafts with
regard to rates of recurrent instability and patient reported outcomes among adult patients.22
Finally, all rehabilitation protocols are not created equal. Analysis of protocols lacking explicit
guidelines was at the authors’ discretion. For example, details regarding patellar mobilization
such as whether it was to be performed by a physical therapist vs. the patient and whether it
was to be applied in a sustained vs. an oscillatory manner were not incorporated. As such, the
authors chose to include this modality as a stretch as opposed to manual therapy. On the other
hand, certain protocols were more robust than others; some were even cited by other
institutions. Given their increased reach and implied credibility, such protocols may represent
more of an industry standard or best practice, but were weighed equally in our data analysis.
Conclusions
This study reveals that minority of U.S. academic orthopaedic institutions publish MPFL
reconstruction rehabilitation protocols online. While our understanding of best practice with
regard to MPFL rehabilitation continues to evolve, protocols should strive to incorporate those
modalities and metrics that are proven to be clinically beneficial. The high degree of variability in
both the composition and timing of rehabilitation components across online protocols highlights
the need for the creation of an evidence-based, standardized MPFL rehabilitation protocol in an
effort to improve patient care.
Accepted Manuscript
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Table 1. MPFL Rehabilitation Rubric Components
Postoperative Adjunctive Therapies Brace use, neuromuscular electric
stimulation, cryotherapy, continuous
passive motion, patellofemoral taping
Range of Motion and Weightbearing Flexion/extension goals, weight-bearing
parameters
Strengthening Straight-leg raise, quadriceps sets, step
up/down, mini-squats, leg press, lunges,
ankle pumps, hamstring curls, squats,
resisted straight-leg raise, wall sits, single
leg squats
Stretching Patellar mobilization, sit/reach hamstring
stretch, gastrocnemius/soleus stretch,
supine quadriceps stretch, runner’s (hip-
flexor) stretch
Proprioception Weight shifting, balance board, one leg
balance, ball toss, mini-trampoline balance,
knee theraband, perturbation
Return to Basic Activity Stationary biking (high seat, low resistance
and moderate resistance), jogging, stair
climber, treadmill, normal gait training,
aquatic exercises, elliptical, swimming,
backwards walking, backwards running
Return to Athletic Activity Plyometrics, agility, cutting/pivoting
“sports-specific” drills, return to training
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