MPFL Reconstruction Rehabilitation.
What is the MPFL and why is it reconstructed?
The medial patellofemoral ligament (MPFL) is a ligament on the inner side of the knee that runs from the medial femoral condyle to the medial border of the patella. Its primary function is to act as the main passive restraint against lateral displacement of the patella — preventing the kneecap from sliding outward. The MPFL provides approximately 50 to 60% of the restraining force against lateral patellar translation, making it the most important passive stabiliser of the patellofemoral joint.
When the patella dislocates laterally — the kneecap slipping out to the outside of the knee — the MPFL is almost always torn in the process. In many patients a single dislocation will heal adequately with conservative management and the patella remains stable. However in a significant proportion of patients — particularly those with underlying anatomical risk factors — the patella continues to dislocate or sublux repeatedly, producing the pattern of recurrent patella instability that significantly limits activity, causes pain and cartilage damage, and ultimately requires surgical stabilisation.
MPFL reconstruction surgically restores the restraint that the torn or attenuated MPFL can no longer provide — using a tendon graft (typically the gracilis tendon or a synthetic ligament) to reconstruct the ligament and re-establish the passive medial restraint of the patella.
Who needs MPFL reconstruction?
MPFL reconstruction is indicated for recurrent patella instability — typically following two or more patella dislocations — where conservative management has failed to restore stability and the patient's quality of life and activity level are significantly affected. It is most commonly performed in young, active patients — adolescents and young adults — who have sustained patella dislocations during sport or physical activity and continue to experience instability that prevents return to their pre-injury activity level.
Several anatomical factors increase the risk of recurrent patella dislocation and influence the surgical approach — trochlear dysplasia (a shallow or absent trochlear groove), patella alta (a high-riding patella), an increased tibial tubercle to trochlear groove (TT-TG) distance, and generalised joint hypermobility are the most clinically significant. Where significant trochlear dysplasia or an elevated TT-TG distance is present, additional bony procedures — trochleoplasty or tibial tubercle osteotomy — may be performed alongside the MPFL reconstruction, modifying the rehabilitation timeline and approach.
What does the surgery involve?
MPFL reconstruction uses a tendon graft — most commonly the gracilis tendon harvested from the medial side of the knee — to recreate the medial patellofemoral ligament. The graft is fixed to the medial border of the patella and tunnelled to the medial femoral condyle where it is secured with a fixation device. The result is a reconstructed ligament that provides the medial restraint the native MPFL can no longer offer.
Where a tibial tubercle osteotomy has been performed alongside the MPFL reconstruction — cutting and repositioning the tibial tubercle to improve the alignment of the patella in the trochlear groove — the early rehabilitation is more conservative, as the osteotomy site must heal before significant loading is appropriate.
Your surgeon's specific post-operative protocol guides the weight-bearing restrictions, range of motion limits and brace requirements in the early period, and our physiotherapy program works within these parameters at each phase.
Why is physiotherapy essential after MPFL reconstruction?
Surgery restores the passive medial restraint of the patella — but it cannot rebuild the dynamic neuromuscular control of the knee that protects the reconstruction during functional loading. The vastus medialis oblique (VMO), hip abductors and gluteal muscles all contribute to dynamic patella stability and are consistently impaired following patella dislocation and surgery. Without specific rehabilitation these deficits persist, placing the reconstruction under inappropriate stress and increasing the risk of recurrent instability.
Additionally the fear of redislocation — which is extremely common after recurrent patella instability — must be specifically addressed through graduated exposure to the provocative positions and activities that previously caused dislocation. Rehabilitation that addresses both the physical and psychological components of return to sport produces significantly better outcomes than a purely physical approach.
What does rehabilitation involve?
Weeks 0 to 6 — protected phase
In the immediate post-operative period the knee is protected in a brace, with weight-bearing as tolerated on crutches from day one in most protocols. The specific brace settings — the range of motion permitted — are determined by your surgeon and advanced progressively over the first six weeks.
Physiotherapy in this phase focuses on swelling management, quadriceps activation — particularly VMO activation — and early range of motion within brace parameters. Straight leg raises, isometric quadriceps sets and hip strengthening in non-provocative positions maintain lower limb function while the graft heals. Gait retraining — restoring normal walking mechanics as brace restrictions are progressively lifted — is an important early focus.
Where a gracilis graft has been harvested, early hamstring loading is avoided to protect the donor site during healing.
Weeks 6 to 12 — progressive strengthening
As brace restrictions are lifted and full weight-bearing is restored, the rehabilitation advances to progressive closed chain strengthening — squats, lunges, step exercises and leg press in ranges that load the quadriceps and gluteals without stressing the reconstruction. VMO-specific exercises and hip abductor strengthening address the specific dynamic stabiliser deficits that predispose to lateral patellar translation.
Real time ultrasound guides VMO activation where inhibition from pain and swelling has disrupted normal firing patterns. Proprioceptive retraining — balance and stability exercises on progressively challenging surfaces — rebuilds the reflexive joint protection responses that are disrupted by ligament injury and surgery.
Patellofemoral loading is progressed carefully — the reconstruction is stressed by deep knee flexion and high patellofemoral contact force activities in the early phases, and exercise selection reflects this.
Weeks 12 to 24 — functional rehabilitation and return to sport
Progressive return to running, change of direction, jumping and sport-specific activity follows criteria-based progression — objective strength testing, single-leg hop tests and functional movement assessment confirming readiness for each stage. Running typically begins at 12 to 16 weeks for isolated MPFL reconstruction, subject to meeting strength and movement quality criteria.
For patients who have also undergone a tibial tubercle osteotomy, return to impact activity is typically delayed by four to six weeks compared to isolated MPFL reconstruction, as the osteotomy site requires adequate healing before high-impact loading is appropriate.
The fear of redislocation — addressed through graduated exposure to previously provocative positions under controlled conditions with the physiotherapist present — is a specific focus of the later rehabilitation phase that is often underemphasised but critical for genuine return to sport confidence.
Return to full contact sport and unrestricted activity typically occurs at six to nine months for isolated MPFL reconstruction, subject to meeting objective return-to-sport criteria.
Managing underlying hypermobility
For patients with generalised joint hypermobility — a significant risk factor for recurrent patella instability — rehabilitation must address the broader neuromuscular stability deficits that hypermobility produces rather than focusing solely on the reconstructed MPFL. Our specialist experience in hypermobility management through Yulia Khasyanova is directly relevant to the hypermobile patient population undergoing MPFL reconstruction.
Clinical Pilates provides an excellent controlled environment for progressive VMO, hip stabiliser and neuromuscular control work — particularly well suited to the hypermobile patient population. Dry needling manages quadriceps, VMO and hip flexor trigger points. Real time ultrasound guides VMO and deep stabiliser retraining.
Our physiotherapists Mauricio Bara, Eliane Machado and Bethany Kippen all have experience in patellofemoral and post-surgical knee rehabilitation and are members of the Australian Physiotherapy Association. Mauricio's APA Sports Physiotherapist credentials are directly relevant to the return-to-sport decision-making central to MPFL reconstruction rehabilitation.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
The medial patellofemoral ligament (MPFL) is a ligament on the inner side of the knee that runs from the medial femoral condyle to the medial border of the patella. Its primary function is to act as the main passive restraint against lateral displacement of the patella — preventing the kneecap from sliding outward. The MPFL provides approximately 50 to 60% of the restraining force against lateral patellar translation, making it the most important passive stabiliser of the patellofemoral joint.
When the patella dislocates laterally — the kneecap slipping out to the outside of the knee — the MPFL is almost always torn in the process. In many patients a single dislocation will heal adequately with conservative management and the patella remains stable. However in a significant proportion of patients — particularly those with underlying anatomical risk factors — the patella continues to dislocate or sublux repeatedly, producing the pattern of recurrent patella instability that significantly limits activity, causes pain and cartilage damage, and ultimately requires surgical stabilisation.
MPFL reconstruction surgically restores the restraint that the torn or attenuated MPFL can no longer provide — using a tendon graft (typically the gracilis tendon or a synthetic ligament) to reconstruct the ligament and re-establish the passive medial restraint of the patella.
Who needs MPFL reconstruction?
MPFL reconstruction is indicated for recurrent patella instability — typically following two or more patella dislocations — where conservative management has failed to restore stability and the patient's quality of life and activity level are significantly affected. It is most commonly performed in young, active patients — adolescents and young adults — who have sustained patella dislocations during sport or physical activity and continue to experience instability that prevents return to their pre-injury activity level.
Several anatomical factors increase the risk of recurrent patella dislocation and influence the surgical approach — trochlear dysplasia (a shallow or absent trochlear groove), patella alta (a high-riding patella), an increased tibial tubercle to trochlear groove (TT-TG) distance, and generalised joint hypermobility are the most clinically significant. Where significant trochlear dysplasia or an elevated TT-TG distance is present, additional bony procedures — trochleoplasty or tibial tubercle osteotomy — may be performed alongside the MPFL reconstruction, modifying the rehabilitation timeline and approach.
What does the surgery involve?
MPFL reconstruction uses a tendon graft — most commonly the gracilis tendon harvested from the medial side of the knee — to recreate the medial patellofemoral ligament. The graft is fixed to the medial border of the patella and tunnelled to the medial femoral condyle where it is secured with a fixation device. The result is a reconstructed ligament that provides the medial restraint the native MPFL can no longer offer.
Where a tibial tubercle osteotomy has been performed alongside the MPFL reconstruction — cutting and repositioning the tibial tubercle to improve the alignment of the patella in the trochlear groove — the early rehabilitation is more conservative, as the osteotomy site must heal before significant loading is appropriate.
Your surgeon's specific post-operative protocol guides the weight-bearing restrictions, range of motion limits and brace requirements in the early period, and our physiotherapy program works within these parameters at each phase.
Why is physiotherapy essential after MPFL reconstruction?
Surgery restores the passive medial restraint of the patella — but it cannot rebuild the dynamic neuromuscular control of the knee that protects the reconstruction during functional loading. The vastus medialis oblique (VMO), hip abductors and gluteal muscles all contribute to dynamic patella stability and are consistently impaired following patella dislocation and surgery. Without specific rehabilitation these deficits persist, placing the reconstruction under inappropriate stress and increasing the risk of recurrent instability.
Additionally the fear of redislocation — which is extremely common after recurrent patella instability — must be specifically addressed through graduated exposure to the provocative positions and activities that previously caused dislocation. Rehabilitation that addresses both the physical and psychological components of return to sport produces significantly better outcomes than a purely physical approach.
What does rehabilitation involve?
Weeks 0 to 6 — protected phase
In the immediate post-operative period the knee is protected in a brace, with weight-bearing as tolerated on crutches from day one in most protocols. The specific brace settings — the range of motion permitted — are determined by your surgeon and advanced progressively over the first six weeks.
Physiotherapy in this phase focuses on swelling management, quadriceps activation — particularly VMO activation — and early range of motion within brace parameters. Straight leg raises, isometric quadriceps sets and hip strengthening in non-provocative positions maintain lower limb function while the graft heals. Gait retraining — restoring normal walking mechanics as brace restrictions are progressively lifted — is an important early focus.
Where a gracilis graft has been harvested, early hamstring loading is avoided to protect the donor site during healing.
Weeks 6 to 12 — progressive strengthening
As brace restrictions are lifted and full weight-bearing is restored, the rehabilitation advances to progressive closed chain strengthening — squats, lunges, step exercises and leg press in ranges that load the quadriceps and gluteals without stressing the reconstruction. VMO-specific exercises and hip abductor strengthening address the specific dynamic stabiliser deficits that predispose to lateral patellar translation.
Real time ultrasound guides VMO activation where inhibition from pain and swelling has disrupted normal firing patterns. Proprioceptive retraining — balance and stability exercises on progressively challenging surfaces — rebuilds the reflexive joint protection responses that are disrupted by ligament injury and surgery.
Patellofemoral loading is progressed carefully — the reconstruction is stressed by deep knee flexion and high patellofemoral contact force activities in the early phases, and exercise selection reflects this.
Weeks 12 to 24 — functional rehabilitation and return to sport
Progressive return to running, change of direction, jumping and sport-specific activity follows criteria-based progression — objective strength testing, single-leg hop tests and functional movement assessment confirming readiness for each stage. Running typically begins at 12 to 16 weeks for isolated MPFL reconstruction, subject to meeting strength and movement quality criteria.
For patients who have also undergone a tibial tubercle osteotomy, return to impact activity is typically delayed by four to six weeks compared to isolated MPFL reconstruction, as the osteotomy site requires adequate healing before high-impact loading is appropriate.
The fear of redislocation — addressed through graduated exposure to previously provocative positions under controlled conditions with the physiotherapist present — is a specific focus of the later rehabilitation phase that is often underemphasised but critical for genuine return to sport confidence.
Return to full contact sport and unrestricted activity typically occurs at six to nine months for isolated MPFL reconstruction, subject to meeting objective return-to-sport criteria.
Managing underlying hypermobility
For patients with generalised joint hypermobility — a significant risk factor for recurrent patella instability — rehabilitation must address the broader neuromuscular stability deficits that hypermobility produces rather than focusing solely on the reconstructed MPFL. Our specialist experience in hypermobility management through Yulia Khasyanova is directly relevant to the hypermobile patient population undergoing MPFL reconstruction.
Clinical Pilates provides an excellent controlled environment for progressive VMO, hip stabiliser and neuromuscular control work — particularly well suited to the hypermobile patient population. Dry needling manages quadriceps, VMO and hip flexor trigger points. Real time ultrasound guides VMO and deep stabiliser retraining.
Our physiotherapists Mauricio Bara, Eliane Machado and Bethany Kippen all have experience in patellofemoral and post-surgical knee rehabilitation and are members of the Australian Physiotherapy Association. Mauricio's APA Sports Physiotherapist credentials are directly relevant to the return-to-sport decision-making central to MPFL reconstruction rehabilitation.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
