MPFL Reconstruction / Tibial Tubercle Osteotomy (TTO) / Cartilage Graft

Physical Therapy Protocol

Phase I – Maximum Protection (Weeks 0–4)

Goals:

• Protect surgical repair and cartilage graft
• Minimize pain and swelling
• Prevent quadriceps atrophy
• Maintain early ROM within safe limits

Restrictions:

• ROM: 0°–90° PROM only for first 6 weeks
• Brace:
  • Locked in full extension (0–0°) for Weeks 0–4
  • 0°–90° range allowed between Weeks 4–6
  • Unlocked at Week 6
• Weight Bearing: Non-weight bearing (NWB) for 8 weeks

Exercises:

• Flexion/Extension – wall slides
• Flexion/Extension – seated
• Patella/Tendon mobilization
• Extension mobilization
• Quad sets
• Ankle pumps
• Sit and reach for hamstrings (towel)
• Balance series

Cardiovascular:

• Bike/Rowing with well leg only

Phase II – Protected Progression (Weeks 5–8)

Goals:

• Controlled advancement of ROM beyond 90°
• Begin isometric strength and neuromuscular control
• Maintain cardiovascular fitness

Restrictions:

• Continue PROM limit if <6 weeks
• Still NWB through Week 8
• Brace at 0–90° range

Exercises:

• Toe and heel raises
• Continue previous exercises
• Hamstring sets
• Double knee bends
• Bike with both legs – no resistance (from Week 6)
• Balance drills

Cardiovascular:

• Continue rowing and bike (no resistance)
• Aquajogging (Week 7+)
• Begin treadmill walking at 7% incline

Phase III – Strength & Reintroduction (Weeks 9–12)

Goals:

• Transition to weight-bearing
• Strengthen key lower extremity groups
• Initiate light dynamic activity

Restrictions:

• Weight-bearing begins at Week 9 as tolerated
• Progress slowly from brace as cleared

Exercises:

• Double leg bridges
• Reverse lunges – static hold
• Resistance cord work
• Balance squats
• Single leg deadlifts
• Leg press
• Begin elliptical and stair stepper
• Rowing machine
• Swimming with fins

Phase IV – Functional Strengthening & Sport Prep (Weeks 13–20)

Goals:

• Enhance neuromuscular control
• Normalize strength for higher-level function
• Begin agility and linear running

Exercises:

• Continue all previous strength work
• Running progression (Week 12–16):
• Initial: single-plane jogging
• Advance: multi-directional movements (Week 16–20)
• Begin sports test prep
• Outdoor biking, hiking, snowshoeing

Phase V – Return to Sport and High-Level Activity (Weeks 20–24+)

Goals:

• Return to full strength, endurance, and coordination
• Resume high-impact and sport-specific activity

Exercises:

• Complete functional sports testing
• High-level agility work
• Initiate return to sport:
• Golf
• Skiing
• Basketball
• Tennis
• Football
• Soccer