Abstract
Purpose of review
To review postoperative rehabilitation protocols after surgery for patellar instability, including medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy (TTO), trochleoplasty, and combined procedures. A secondary aim was to compare published recommendations with guidance generated by selected artificial intelligence (AI) platforms.
Recent findings
Sixty three protocol entries were included: 35 isolated MPFLR, 9 isolated TTO, 4 isolated trochleoplasty, and 15 combined procedures. Isolated MPFLR showed the most consistent rehabilitation pattern, favoring immediate weight bearing as tolerated (66%, p < 0.001), locked bracing for up to 6 weeks (63%, p < 0.001), and full ROM by 6 to 12 weeks (51%, p = 0.002). Isolated TTO protocols recommended delayed or non weight bearing (56%), locked brace duration greater than 6 weeks (67%), and full ROM by 6 to 12 weeks (44%), with no significant predominance (all p > 0.05). Trochleoplasty protocols were too few and heterogeneous. Combined procedures were mostly protective but variable overall. RTS criteria were mostly time, functional, and strength based (76%-89%), whereas psychological readiness (43%) and physician approval (22%) were infrequent. AI generated protocols broadly reproduced MPFLR rehabilitation principles but lacked procedure specific differentiation.
Summary
Rehabilitation protocols following patellar instability surgery remain highly variable, particularly for non MPFLR procedures. Isolated MPFLR protocols generally follow a more structured and accelerated pathway, whereas rehabilitation after TTO, trochleoplasty, and combined procedures remains less clearly defined and more protective. RTS decisions rely mainly on time, strength, and functional based criteria, whereas psychological readiness remains underutilized. AI based tools may serve as supportive decision making aids but currently require integration with clinical judgment and procedure-specific expertise.
Keywords: Patellar instability, Rehabilitation, Medial patellofemoral ligament reconstruction, Tibial tubercle osteotomy, Trochleoplasty, Return to sport, Artificial intelligence
Introduction
Patellar instability is a complex clinical entity that encompasses a spectrum from first time dislocation to recurrent instability and chronic patellofemoral maltracking [1, 2]. It has a multifactorial etiology including abnormalities in soft tissue restraints, limb alignment, trochlear morphology, and patellar height [2, 3]. When nonoperative treatment fails to prevent recurrent instability, surgical management is tailored to the underlying pathoanatomy [4, 5]. Among the principal surgical strategies are medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy (TTO) for anteromedialization and/or distalization, and trochleoplasty, performed either in isolation or in combination depending on individual risk factors [6–8]. Despite advances in surgical treatment, postoperative rehabilitation remains a critical but insufficiently standardized component of care [4, 7, 9].
Rehabilitation is central to restoring function, facilitating return to sport, and minimizing complications such as stiffness, persistent instability, and graft or fixation failure [4, 9]. However, existing literature demonstrates substantial variability in rehabilitation protocols following MPFLR surgery [10–12]. Recent consensus statements have marked a lack of agreement regarding postoperative rehabilitation for TTO and trochleoplasty procedures [7]. As such clear procedure specific rehabilitation guidance remains limited.
The aim of this structured review was to compare postoperative rehabilitation recommendations following surgical treatment for patellar instability, including MPFLR, TTO, trochleoplasty, and combined procedures, as presented in peer reviewed publications and publicly available rehabilitation protocols. Additionally, the study explored how these recommendations align with rehabilitation guidance generated by selected AI platforms. The research sought to identify areas of consensus, points of divergence, and domains where procedure specific guidance remains lacking. We hypothesized that rehabilitation protocols after patellar instability surgery would exhibit significant variability, especially following procedures involving bony realignment or combined stabilization.
Methods
Study Design
This was a structured review of postoperative rehabilitation protocols following surgical treatment for patellar instability. The review focused on rehabilitation recommendations after medial patellofemoral ligament reconstruction (MPFLR), tibial tubercle osteotomy (TTO), trochleoplasty, and combined procedures. In addition, an exploratory analysis was performed to evaluate the recommendations generated by widely used large language model (LLM) artificial intelligence (AI) platforms.
Information Sources and Search Strategy
This structured review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) 2020 guidelines where appropriate. Electronic searches were performed by two reviewers (JS and OCM) in PubMed/MEDLINE, Biblioteca Virtual en Salud (BVS), and Scientific Electronic Library Online (SciELO).
In addition, publicly available institutional rehabilitation protocols were identified through structured web based searches. Searches were conducted between January and February 2026 using combinations of the following terms: “patellar instability,” “MPFL reconstruction,” “medial patellofemoral ligament reconstruction,” “tibial tubercle osteotomy,” “Fulkerson osteotomy,” “trochleoplasty,” “rehabilitation,” “physical therapy protocol,” and “return to sport.” Equivalent searches were performed in English, Hebrew, Spanish, and Arabic by native speakers.
To reflect real world access to rehabilitation guidance, web based searches were limited to the first 10 pages of results for each search term combination. The search engine, search date, language, and retrieved source type were recorded. When institutional protocols were available as downloadable documents, the protocol content was extracted from the publicly accessible file. The review was intended to characterize available protocol recommendations rather than to evaluate clinical outcomes.
Eligibility Criteria and Selection Process
Two reviewers (JS and OCM) independently screened titles, abstracts, full text articles, and publicly available protocols for eligibility. Disagreements were resolved by discussion and consensus. Duplicate records were removed before full text review. Sources were eligible for inclusion if they described postoperative rehabilitation after MPFLR, TTO, trochleoplasty, or a combination of these procedures and reported at least one rehabilitation parameter of interest. Sources were excluded if they focused exclusively on nonoperative management, did not include postoperative rehabilitation details, or were not applicable to the surgical procedures of interest. Pediatric and adolescent protocols were not excluded if the rehabilitation recommendations were procedure based and clinically applicable to patellar instability surgery.
Data Collection
Extracted variables included source type, institution type, geographic origin, language, surgical procedure, and rehabilitation recommendations. Rehabilitation variables of interest were weight bearing status, bracing strategy, timing of brace discontinuation, range of motion (ROM) milestones, and return to sport (RTS) criteria.
Protocols describing more than one surgical procedure, such as MPFLR combined with TTO, were classified as combined procedures. Institutional source type was categorized as private clinic, academic institution, hospital, or review article. Geographic origins were grouped into continents. For analysis of full ROM milestones, recommendations were grouped into predefined intervals of 0 to 6 weeks, 6 to 12 weeks, and more than 12 weeks. When protocols reported a range that crossed more than one category, the later end of the reported range was used for classification, because this best reflected the time by which unrestricted ROM was expected. Protocols that did not specify a full ROM milestone were categorized as unspecified. These assignments were made before comparative analysis to permit uniform categorical comparison across protocols. Because several protocols reported broad or overlapping ROM ranges, ROM milestone analyses should be interpreted as approximate.
Data Synthesis and Statistical Analysis
Categorical rehabilitation recommendations were summarized as counts and proportions. Because protocol categories were heterogeneous and sample sizes were small for several procedures, statistical comparisons were considered exploratory. Chi square goodness of fit tests were used to evaluate whether recommendation distributions within each procedure differed from an equal distribution across categories when assumptions were met. When expected cell counts were small, findings were interpreted descriptively, and Fisher’s exact test was used. Statistical analysis was performed using RStudio (version 2026.01.0), and statistical significance was set at p < 0.05.
RTS timing recommendations were analyzed as continuous variables in months. Overall and procedure specific distributions were summarized using median and interquartile range. Intra procedure variability was further described using standard deviation, variance, and coefficient of variation. Inter procedure differences were assessed using the Kruskal Wallis test.
Exploratory Analysis of AI Generated Protocols
An exploratory AI analysis was performed using ChatGPT, Gemini, and Open Evidence. Each platform was queried during the study period using standardized prompts requesting postoperative rehabilitation guidance after MPFLR, TTO, trochleoplasty, and combined patellar stabilization procedures. Outputs were recorded at the time of generation and compared qualitatively with respect to weight bearing, bracing, ROM goals, brace discontinuation, and RTS criteria. Because AI outputs may vary over time and across user settings, this analysis was considered exploratory and descriptive.
Results
Protocol Selection
A total of 3,034 records were initially identified in the systematic search. After duplicate removal and title based exclusion, 214 records remained for screening. Of these, 109 were excluded because they did not include a rehabilitation protocol and/or RTS criteria. A total of 105 reports were sought for retrieval, of which 13 were not retrieved or were duplicates, leaving 92 reports for full text eligibility assessment. After full text review, 33 reports were excluded because of insufficient protocol detail and/or RTS information. Ultimately, 63 protocols were included in the final review (Fig. 1) [13–71].
Fig. 1.
PRISMA Flow Diagram for Source Selection Process
Characteristics of included Protocols
Table 1 summarizes the included protocol entries. Of the 63 protocols included in the final analysis, 35 (56%) addressed isolated MPFLR, 9 (14%) addressed isolated TTO, 4 (6%) addressed isolated trochleoplasty, and 15 (24%) addressed combined procedures, most commonly MPFLR combined with TTO. Most protocols originated from North America (68%, 43/63), followed by Europe (17%, 11/63), South America (10%, 6/63), and Australia (5%, 3/63). Most protocols were published by private practice clinics (40%, 25/63), followed by academic institutions (27%, 17/63), and hospitals (9%, 6/63). The other 24% (15/63) were present in review articles. No protocols met inclusion criteria in Hebrew or Arabic.
Table 1.
Systematically Reviewed Rehabilitation Protocols
| Protocol | Year | Region | Source Type | Procedure |
|---|---|---|---|---|
| Melbourne Hip & Knee(44) | NS | AUS | Private Practice | MPFLR |
| York Orthopaedics(48) | NS | UK | Private Practice | MPFLR |
| Puzzuoli & Khammash, Lothian Physiotherapy(26) | 2022 | UK | Hospital | MPFLR |
| Damian Clark, MD(31) | NS | UK | Private Practice | MPFLR |
| Denton, Sheffield Children’s NHS(28) | 2019 | UK | hospital | MPFLR |
| Calleja Nicolás, Univ. de Salamanca(52) | 2020 | Spain | Review | MPFLR |
| Brown Univ. University Orthopedics(37) | NS | USA | Academic | MPFLR |
| Wulf, Twin Cities Orthopedics(29) | NS | USA | Private Practice | MPFLR |
| Mass General Brigham(58) | 2024 | USA | Academic | MPFLR |
| UVA Health, University of Virginia(49) | NS | USA | Academic | MPFLR |
| Ganley et al., CHOP(15) | 2023 | USA | Hospital | MPFLR |
| Ingle et al., Ohio State Wexner(32) | 2015 | USA | Academic | MPFLR |
| Frantz, Texas Health(38) | NS | USA | Private Practice | MPFLR |
| Heard et al., Banff Sport Medicine(30) | 2019 | CAN | Private Practice | MPFLR |
| Sanford Orthopedics Sports Med.(41) | 2024 | USA | Academic | MPFLR |
| Bradley Smith, MD(57) | NS | USA | Private Practice | MPFLR |
| UW Health Sports Medicine(35) | NS | USA | Academic | MPFLR |
| Kwadwo Owusu-Akyaw, MD(40) | NS | USA | Private Practice | MPFLR |
| Matthew Posner, MD(42) | 2020 | USA | Private Practice | MPFLR |
| Hsu et al., Stanford Medicine(18) | 2025 | USA | Review | MPFLR |
| Kai Mithoefer, MD(51) | NS | USA | Private Practice | MPFLR |
| Manske & Prohaska, Wichita State University(56) | 2017 | USA | Review | MPFLR |
| Jonathan Watson, MD(60) | NS | USA | Private Practice | MPFLR |
| Watson et al., Univ. of Kentucky(24) | 2022 | USA | Review | MPFLR |
| University of Delaware(27) | NS | USA | Academic | MPFLR |
| McGee et al., The Johns Hopkins Hospital(53) | 2017 | USA | hospital | MPFLR |
| Lampros et al., Massachusetts General(55) | 2021 | USA | Review | MPFLR |
| Marangoni et al., Sanatorio Allende(19) | 2025 | Argentina | Review | MPFLR |
| Sarassa et al., Clínica del Campestre(36) | 2020 | Colombia | Review | MPFLR |
| Maestu et al., CETEA(22) | 2019 | Argentina | Review | MPFLR |
| Masquijo & Carabajal, Asoc Argent Ortop Traumatol(23) | 2024 | Argentina | Academic | MPFLR |
| Dalhousie Orthopaedics, QEII Health Sciences(47) | 2016 | CAN | Academic | MPFLR |
| Ortho Rhode Island(39) | NS | USA | Private Practice | MPFLR |
| Hysing-Dahl & Inderhaug, Haraldsplass Deaconess(54) | 2024 | Norway | Review | MPFLR |
| Saper et al., Seattle Children’s(63) | 2019 | USA | Review | MPFLR |
| Díaz Allende et al., Grupo Estudio Rodilla(17) | 2021 | Chile | Review | TTO |
| The British Patellofemoral Society(66) | NS | UK | academic | TTO |
| Jonathan Watson, MD(61) | NS | USA | Private Practice | TTO |
| Corey Kendall, MD(64) | 2016 | USA | Private Practice | TTO |
| Brandon M. Tauberg, MD(65) | NS | USA | Private Practice | TTO |
| Kwadwo Owusu-Akyaw, MD(67) | NS | USA | Private Practice | TTO |
| Smith, Utah Orthopaedic Specialists(59) | NS | USA | Private Practice | TTO |
| Morgan et al., Univ. of Connecticut(20) | 2022 | USA | Academic | TTO |
| Chatterji et al., Rothman Orthopaedic Inst.(62) | 2020 | USA | Review | TTO |
| Damian Clark, MD(68) | NS | UK | Private Practice | Troch |
| Melbourne Hip & Knee(72) | NS | Australia | Private Practice | Troch |
| Brunst et al., Ohio State Wexner(69) | 2024 | USA | Academic | Troch |
| Reinholz et al., Mayo Clinic(21) | 2023 | USA | Academic | Troch |
| Damian Clark, MD(16) | NS | UK | Private Practice | MPFLR + TTO |
| Dalhousie Orthopaedics, QEII Health Sciences(47) | 2016 | CAN | Academic | MPFLR + TTO |
| Ohio State Wexner(34) | 2015 | USA | Academic | MPFLR + TTO |
| Ortho Rhode Island(39) | NS | USA | Private Practice | MPFLR + TTO |
| Orthopedic & Sports Medicine Center(50) | NS | USA | Private Practice | MPFLR + TTO |
| Norris & McNicholas, McNicholas Knee Clinic(70) | 2020 | UK | Private Practice | Troch (+/- MPFLR +/- Osteotomy) |
| Ben Mayo, MD(73) | 2024 | USA | Private Practice | Troch + MPFLR |
| Hysing-Dahl & Inderhaug, Haraldsplass Deaconess(54) | 2024 | Norway | Review | MPFLR/TTO |
| The Children’s Hospital at Westmead(46) | 2022 | AUS | Hospital | Combined |
| Andrew Parker, MD, Texas Health(43) | NS | USA | Private Practice | MPFLR + TTO |
| Ganley et al., CHOP(33) | 2023 | USA | Hospital | MPFLR + TTO |
| Boden, University of Louisville Health(71) | NS | USA | Academic | Troch (+/- MPFLR +/- Osteotomy) |
| Raney et al., Univ of Pittsburgh(25) | 2025 | USA | Academic | MPFLR +/- TTO +/- Troch |
| Firman, Grupo Médico Teuos(45) | 2025 | Argentina | Review | MPFLR + TTO |
| Saper et al., Seattle Children’s(63) | 2019 | USA | Review | MPFLR + TTO |
NS = not specified, MPFL medial patellofemoral ligament reconstruction, TTO tibial tuberosity osteotomy, Troch trochleoplasty
Protocol Variability
Overall, isolated MPFLR protocols demonstrated the clearest pattern across several rehabilitation domains, particularly weight bearing, brace type, and brace duration (Table 2). In contrast, TTO protocols showed no significant predominance of any single recommendation across the evaluated rehabilitation domains. Trochleoplasty protocols were limited in number; weight bearing recommendations appeared heterogeneous, whereas the remaining domains could not be meaningfully analyzed because of the small sample size. Combined procedures also showed broad variability, with no significant predominance of a single recommendation in most rehabilitation domains.
Table 2.
Procedure-specific postoperative rehabilitation recommendations
| Procedure | MPFLR (n = 35) |
TTO (n = 9) |
Trochleoplasty (n = 4) |
Combined Procedures (n = 15) |
|---|---|---|---|---|
| Weight bearing restrictions | ||||
| Immediate WBAT | 23 (66%) | 2 (22%) | 2 (50%) | 5 (33%) |
| PWB | 9 (26%) | 1 (11%) | 1 (25%) | 6 (40%) |
| NWB/delayed | 2 (6%) | 5 (56%) | 1 (25%) | 3 (20%) |
| Unspecified | 1 (3%) | 1 (11%) | 0 (0%) | 1 (7%) |
| P value | < 0.001 | 0.197 | 0.779 | 0.607 |
| Bracing restrictions | ||||
| Locked (in extension) | 19 (54%) | 6 (67%) | 1 (25%) | 8 (53%) |
| Unlocked/hinged | 9 (26%) | 2 (22%) | 0 (0%) | 4 (27%) |
| Unspecified | 7 (20%) | 1 (11%) | 3 (75%) | 3 (20%) |
| P value | 0.059 | 0.157 | - | 0.248 |
| Brace duration | ||||
| 0–6 weeks | 22 (63%) | 2 (22%) | 0 (0%) | 7 (47%) |
| > 6 weeks | 3 (9%) | 6 (67%) | 1 (25%) | 5 (33%) |
| Unspecified | 10 (29%) | 1 (11%) | 3 (75%) | 3 (20%) |
| P value | < 0.001 | 0.655 | - | 0.564 |
| Brace weaning criteria | ||||
| Time-based | 10 (29%) | 3 (33%) | 0 (0%) | 2 (13%) |
| Functional-based | 16 (46%) | 3 (33%) | 1 (25%) | 9 (60%) |
| Unspecified | 9 (26%) | 3 (33%) | 3 (75%) | 4 (27%) |
| P value | 0.239 | 1.000 | - | 0.035 |
| Full ROM milestones | ||||
| 0–6 weeks | 12 (37%) | 3 (33%) | 0 (0%) | 2 (13%) |
| 6–12 weeks | 18 (51%) | 4 (44%) | 2 (50%) | 8 (53%) |
| > 12 weeks | 2 (6%) | 1 (11%) | 0 (0%) | 3 (20%) |
| Unspecified | 3 (9%) | 1 (11%) | 2 (50%) | 2 (13%) |
| P value | 0.002 | 0.417 | - | 0.092 |
| RTS criteria | ||||
| Time-based | 32 (91%) | 8 (89%) | 3 (75%) | 14 (93%) |
| Functional-based | 32 (91%) | 7 (78%) | 4 (100%) | 14 (93%) |
| Strength-based | 28 (80%) | 8 (89%) | 3 (75%) | 11 (73%) |
| Psychological-based | 15 (42%) | 3 (33%) | 2 (50%) | 9 (60%) |
| Physician approval | 7 (23%) | 2 (22%) | 2 (50%) | 4 (44%) |
Values are numbers and valid proportions (%). P values follow Chi-square goodness-of-fit tests, meaning values > 0.05 indicate variability in recommendations. MPFLR medial patellofemoral ligament reconstruction, TTO tibial tubercle osteotomy, WBAT weight bearing as tolerated, PWB partial weight bearing, NWB non-weight bearing, Functional-based brace weaning criteria = straight leg raise (SLR) or quadriceps control tests, ROM range-of-motion, RTS return-to-sports, Functional-based RTS criteria = hop or Y-balance tests, Strength-based RTS criteria = limb symmetric index (LSI) threshold ≥ 80–90%, Psychological-based RTS criteria = MPFL/ACL Return to Sport after Injury (RSI), Tampa Scale of Kinesiophobia (TSK), Marx Activity Scale, and subjective confidence assessments
Weight Bearing Recommendations
Weight bearing recommendations differed across procedures (Table 2). In isolated MPFLR protocols, immediate weight bearing as tolerated (WBAT) was the predominant recommendation, reported in 66% (23/35) of protocols (p < 0.001). In contrast, no statistically significant predominance of a single recommendation was observed for the other procedures (all p > 0.05; Table 2). Isolated TTO protocols showed a more restrictive trend, with 56% (5/9) recommending non weight bearing (NWB) or delayed weight bearing for more than 6 weeks and only 22% (2/9) permitting immediate WBAT. Among isolated trochleoplasty protocols, recommendations were heterogeneous: two of four allowed immediate WBAT, whereas one of four recommended partial weight bearing (PWB) for 2 to 6 weeks and one of four recommended delayed weight bearing for more than 6 weeks. Combined procedures were also variable, with 40% (6/15) recommending PWB for 2 to 6 weeks, 33% (5/15) allowing immediate WBAT, and 20% (3/15) recommending NWB or delayed weight bearing for more than 6 weeks. Overall, these findings suggest relative agreement toward immediate WBAT after isolated MPFLR, whereas weight bearing recommendations for other procedures remain less consistent.
Bracing Recommendations
Bracing recommendations also varied across procedures (Table 2). In isolated MPFLR protocols, locked bracing was the predominant recommendation, reported in 54% (19/35) of protocols (p = 0.029). Brace duration after isolated MPFLR was also relatively consistent, with 0 to 6 weeks being the most common recommendation in 63% (22/35) of protocols (p < 0.001). In contrast, no statistically significant predominance of a single brace type or duration was observed for TTO, trochleoplasty, or combined procedures (all p > 0.05). TTO protocols showed a trend favoring locked bracing and brace use for more than 6 weeks, whereas combined procedures were more evenly distributed across reported durations. Among isolated trochleoplasty protocols, brace type and duration were frequently not specified. With respect to brace weaning, no single strategy predominated in isolated MPFLR, TTO, or trochleoplasty protocols (all p > 0.05). In combined procedures, functional based weaning criteria were the most common recommendation, reported in 60% (9/15) of protocols (p = 0.035). Overall, these findings suggest relative agreement regarding brace type and early duration after isolated MPFLR, whereas bracing recommendations for other procedures remain less consistent.
ROM Milestones
The timing of full ROM recovery varied across procedures, although most protocols targeted achievement within the first 12 postoperative weeks (Table 2). Among isolated MPFLR protocols, full ROM was most commonly targeted between 6 and 12 weeks, reported in 51% (18/35) of protocols, whereas 34% (12/35) targeted full ROM within 0 to 6 weeks (p = 0.002). TTO protocols showed a similar descriptive pattern, with 33% (3/9) targeting full ROM by 0 to 6 weeks and 44% (4/9) by 6 to 12 weeks, although no statistically significant predominance of a single recommendation was observed (p = 0.417). In isolated trochleoplasty protocols, half of the protocols (2/4) targeted full ROM between 6 and 12 weeks, whereas the remainder did not specify a milestone. Combined procedures most commonly targeted full ROM between 6 and 12 weeks (53%, 8/15), while 13% (2/15) targeted full ROM within the first 6 weeks and 20% (3/15) after more than 12 weeks; however, no statistically significant predominance of a single recommendation was observed (p = 0.092). Overall, these findings suggest relative agreement toward full ROM by 6 to 12 weeks after isolated MPFLR, whereas ROM milestones for the other procedures remain less consistently defined.
RTS Criteria
RTS recommendations were most commonly based on time, functional testing, and strength assessment across all procedure categories (Table 2). Time based criteria were reported in 91% (32/35) of isolated MPFLR protocols, 89% (8/9) of TTO protocols, 75% (3/4) of isolated trochleoplasty protocols, and 93% (14/15) of combined procedures.
Functional criteria, including hop tests and Y Balance assessments, were also frequently incorporated, appearing in 91% (32/35) of MPFLR protocols, 78% (7/9) of TTO protocols, 100% (4/4) of trochleoplasty protocols, and 93% (14/15) of combined procedures. Strength based criteria were similarly common, reported in 80% (28/35) of MPFLR protocols, 89% (8/9) of TTO protocols, 75% (3/4) of trochleoplasty protocols, and 73% (11/15) of combined procedures. In contrast, psychological readiness criteria were reported less frequently across all procedures, ranging from 33% to 60% of protocols, and physician approval was also less commonly included. Overall, these findings suggest relative consistency in the use of time, functional, and strength based RTS criteria across procedures, whereas psychological readiness and physician approval remain less consistently incorporated. Among 56 protocols that specified a time based RTS recommendation, the overall median recommended RTS timing was 6 months (IQR, 4–6) (Table 3). Median recommended timing was 6 months for all procedures, with differing dispersion: MPFLR, 6 months (IQR, 4–6); TTO, 6 months (IQR, 5.75–6); trochleoplasty, 6 months (IQR, 6–7.5); and combined procedures, 6 months (IQR, 6–6). Intra procedure variability was modest overall, and it was greatest for MPFLR (SD, 1.72 months; variance, 2.96; coefficient of variation, 0.32), followed by TTO (SD, 1.51 months; variance, 2.29; coefficient of variation, 0.27), combined procedures (SD, 1.66 months; variance, 2.74; coefficient of variation, 0.27), and trochleoplasty (SD, 1.73 months; variance, 3.00; coefficient of variation, 0.25). Recommended RTS timing did not differ significantly between procedures (Kruskal Wallis chi square = 3.21, df = 3, p = 0.361).
Table 3.
RTS timing
| procedure | n | median_IQR | sd | variance | cv |
|---|---|---|---|---|---|
| Overall | 56 | 6 [4–6] | NA | NA | NA |
| Combined | 13 | 6 [6–6] | 1.66 | 2.74 | 0.27 |
| MPFLR | 32 | 6 [4–6] | 1.72 | 2.96 | 0.32 |
| TTO | 8 | 6 [5.75–6] | 1.51 | 2.29 | 0.27 |
| Trochleoplasty | 3 | 6 [6–7.5] | 1.73 | 3 | 0.25 |
| Kruskalb Wallis | NA | chi-squared = 3.21, df = 3, p = 0.361 |
Qualitative Comparison with AI Generated Rehabilitation Protocols
The three AI platforms generated recommendations that were broadly consistent with general postoperative rehabilitation principles but differed in level of detail and procedure specific differentiation (Table 4). For weight bearing restrictions, across all models, isolated MPFLR was generally associated with WBAT, whereas TTO and trochleoplasty were approached more conservatively with PWB. Bracing recommendations for isolated MPFLR were variable: Gemini and ChatGPT favored locked bracing in extension, whereas Open Evidence supported a no brace strategy. For TTO and trochleoplasty, the three models appeared to agree on locked immobilization. ROM targets were relatively similar across platforms, with all three recommending early progression to 90° of flexion within 2 to 4 weeks, followed by full ROM by 6 to 8 weeks. For RTS, all models incorporated objective criteria, including LSI thresholds of at least 90% and some functional testing. Gemini was the only model to include psychological readiness measures.
Table 4.
Qualitative comparison of AI-generated rehabilitation recommendations
| Procedure | MPFLR | TTO | Trochleoplasty |
|---|---|---|---|
| Weight bearing | |||
| Current analysis | WBAT | NWB | WBAT |
| Gemini | WBAT (V) | PWB (X) | PWB (X) |
| ChatGPT | WBAT (V) | PWB (X) | PWB (X) |
| Open Evidence | WBAT (V) | PWB (X) | Not reported (X) |
| Bracing | |||
| Current analysis |
Locked 0–6 weeks Functional weaning |
Locked > 6 weeks Variable weaning |
Not reported |
| Gemini |
Locked (V) Unspecified time (X) Functional weaning (V) |
Locked (V) Unspecified time (X) Functional weaning (X) |
Locked (X) Unspecified time (X) Functional weaning (X) |
| ChatGPT |
Locked (V) 0–2 weeks (X) Time-based weaning (X) |
Locked (V) > 2 weeks (X) Time-based weaning (V) |
Locked (X) > 2 weeks (X) Time-based weaning (X) |
| Open Evidence | No bracing (X) |
Locked (V) Unspecified time (X) Unspecified weaning (X) |
Not reported (V) |
| Full ROM | |||
| Current analysis | 6–12 weeks | 6–12 weeks | 6–12 weeks |
| Gemini | 4–8 weeks (X) | 4–8 weeks (X) | 4–8 weeks (X) |
| ChatGPT | 2–6 weeks (X) | 2–6 weeks (X) | 2–6 weeks (X) |
| Open Evidence | > 3 weeks (X) | > 3 weeks (X) | > 3 weeks (X) |
| RTS criteria | |||
| Current analysis |
Time based Functional based Strength based |
Time based Functional based Strength based |
Time based Functional based Strength based |
| Gemini |
Functional based (V) Strength based (V) Psychological based (X) |
Functional based (V) Strength based (V) Psychological based (X) |
Functional based (V) Strength based (V) Psychological based (X) |
| ChatGPT |
Time based (V) Functional based (V) Strength based (V) |
Time based (V) Functional based (V) Strength based (V) |
Time based (V) Functional based (V) Strength based (V) |
| Open Evidence |
Functional based (V) Strength based (V) |
Functional based (V) Strength based (V) |
Functional based (V) Strength based (V) |
V – in alignment with current analysis, X – not in alignment with current analysis, MPFLR medial patellofemoral ligament reconstruction, TTO tibial tubercle osteotomy, WBAT weight bearing as tolerated, PWB partial weight bearing, NWB non-weight bearing
Discussion
The key findings of this review are that postoperative rehabilitation protocols after patellar instability surgery remain highly variable. Isolated MPFLR protocols showed the most consistent pattern, generally favoring immediate weight bearing, early bracing, and full ROM by 6 to 12 weeks. In contrast, TTO and combined procedure protocols were typically more protective but less consistently defined, while isolated trochleoplasty protocols were too few to support a representative rehabilitation pathway. RTS recommendations were commonly based on time, strength, and functional criteria, whereas psychological readiness was less consistently incorporated. AI generated protocols reproduced broad rehabilitation principles but lacked sufficient procedure specific granularity.
Protocols following isolated MPFLR generally reflected the least restrictive rehabilitation pathway among the procedures reviewed. Most allowed immediate WBAT, commonly used a locked brace during the early postoperative period, and typically targeted brace discontinuation within the first 6 weeks. Full ROM was most often expected within 6 to 12 weeks, although a substantial proportion of protocols aimed for earlier recovery. RTS progression after MPFLR was usually guided by a combination of time based milestones, functional testing, and strength assessment, suggesting that rehabilitation after isolated soft tissue stabilization is commonly structured around earlier mobilization and progressive restoration of function.
In contrast, protocols following isolated TTO were consistently more protective, particularly with respect to weight bearing and, to a lesser extent, bracing duration. Most TTO protocols recommended delayed or NWB during the early postoperative period, and brace use was common, trending beyond the timelines reported for isolated MPFLR. ROM progression was generally targeted within the first 12 postoperative weeks, but the overall structure of TTO rehabilitation appeared more cautious, likely reflecting the need to protect osseous healing and fixation during the early phases of recovery. RTS criteria remained multifactorial and often included time, strength, and functional testing. Although accelerated rehabilitation following TTO is supported in the literature, it is inconsistently implemented in the reviewed protocols [72].
Isolated trochleoplasty protocols were limited in number and showed substantial variability, which precludes a clear characterization of a typical rehabilitation pathway. Nevertheless, the available protocols suggested that trochleoplasty is generally approached more conservatively than isolated MPFLR, particularly in the early postoperative period.
Combined procedures generally followed the most restrictive component of the surgical intervention and therefore tended to resemble bony procedure rehabilitation more than isolated soft tissue stabilization. In these protocols, delayed or PWB was common, brace use was frequent, and full ROM was more often targeted between 6 and 12 weeks rather than earlier in the recovery course. RTS decisions remained multifactorial.
The variability observed in the present review is consistent with prior studies evaluating online rehabilitation protocols after isolated MPFLR, which have similarly demonstrated substantial heterogeneity in recommendations [10–12]. These findings also align with the modified Delphi consensus statement from the Patellar Instability International Consensus Group, which found no agreement regarding postoperative immobilization or weight bearing strategy [7]. The consensus group suggested that this reflects the limited availability of high level evidence and the continued reliance on surgeon preference and institutional practice patterns. At the same time, the consensus group strongly supported early motion after patellar stabilization surgery to reduce the risk of arthrofibrosis and recommended that full ROM should be achieved by 6 weeks after MPFL repair or reconstruction [7]. In the present review, these recommendations were most closely reflected in isolated MPFLR protocols, which generally favored earlier weight bearing and brace discontinuation within the first 6 weeks. In contrast, TTO and combined procedures followed a more protective course, with delayed weight bearing and later progression of ROM, suggesting that postoperative rehabilitation is shaped not only by general rehabilitation principles but also by the biological demands of the procedure itself. This distinction is biologically intuitive, as rehabilitation after bony realignment procedures must account for osteotomy healing and fixation protection, in contrast to isolated soft tissue reconstruction, where earlier motion may help reduce stiffness and soft tissue adhesions.
The consensus statement also supported the incorporation of psychological readiness, extensor mechanism strength, full ROM, absence of apprehension, and standardized functional testing in RTS decision making [7]. This is broadly consistent with the present review, in which most protocols incorporated time based, strength based, and functional criteria. However, psychological readiness was included far less consistently, suggesting that this remains an underdeveloped component of postoperative rehabilitation. This is noteworthy because patients with patellar instability frequently experience kinesiophobia and reduced confidence, factors that may negatively affect recovery and RTS [9]. Prior work has similarly shown that psychological factors contribute to failure to RTS after patellar stabilization surgery [73]. Together, these findings support a broader rehabilitation model that incorporates both physical recovery and psychological readiness when determining RTS progression.
The exploratory AI analysis adds a contemporary and clinically relevant dimension to the review. Patients and clinicians increasingly encounter AI generated medical guidance, but the present findings suggest that such outputs should be interpreted cautiously in the context of patellar instability rehabilitation. The AI generated protocols generally captured broad principles [74, 75], such as earlier progression after isolated MPFLR and more protective rehabilitation after bony procedures. However, they often lacked the level of procedural specificity needed for clinical implementation, particularly regarding brace discontinuation, weight bearing progression, osteotomy precautions, and RTS decision making.
This limitation is not unexpected. In areas where published protocols and expert recommendations are themselves heterogeneous, AI systems may reproduce general patterns without resolving the underlying clinical uncertainty. Therefore, AI generated rehabilitation guidance may be useful as a broad educational adjunct, but it should not replace surgeon directed, procedure specific rehabilitation protocols developed in collaboration with experienced physical therapists.
The findings of this review have several practical implications. First, although a general rehabilitation pattern can be identified after isolated MPFLR, postoperative pathways after TTO, trochleoplasty, and combined procedures remain less clearly defined. This highlights the need for more procedure specific rehabilitation guidance, particularly for surgeries involving osteotomy or trochlear reshaping. Second, RTS recommendations should move beyond time alone and more consistently incorporate strength, functional performance, absence of apprehension, and psychological readiness. Finally, although AI generated protocols may provide a useful high level framework, they lack sufficient nuance to guide rehabilitation without professional interpretation.
Several limitations of this review should be acknowledged. First, this review was limited to published, publicly available rehabilitation protocols and may not reflect internal institutional or surgeon specific protocols that are not publicly available. Second, the included protocols were heterogeneous in format, level of detail, and source type, and many lacked sufficient procedural specificity, which limited direct comparisons across rehabilitation domains. Third, isolated trochleoplasty protocols were few, limiting the ability to define a representative rehabilitation pathway for this procedure. Fourth, because this review evaluated reported protocol recommendations rather than patient level outcomes, it cannot determine whether one rehabilitation strategy is clinically superior to another. The search was limited to protocols published in English, Spanish, Arabic, and Hebrew, and may have excluded relevant data from other languages, potentially limiting the generalizability of the findings. Finally, the exploratory AI analysis was limited to selected publicly available platforms and reflects their outputs at the time of assessment, which may change over time as these models evolve.
In conclusion, rehabilitation protocols following patellar instability surgery remain highly variable, particularly for non MPFLR procedures. Isolated MPFLR protocols generally follow a more structured and accelerated pathway, whereas protocols after TTO, trochleoplasty, and combined procedures are less clearly defined and more protective. RTS decisions rely mainly on time, strength, and functional criteria, whereas psychological readiness remains underutilized. AI based tools are likely to serve as supportive decision making aids in this context; given their increasing adoption and ongoing investment, they should not be overlooked but integrated alongside clinical judgment and expreience, with their role continuing to evolve as further evidenc emerges.
Key References
- Hurley ET, Sherman SL, Chahla J, et al. (2023)
- ○ This modified Delphi consensus represents a major effort to standardize care in patellar instability. Still, agreement remains limited particularly in postoperative rehabilitationvhighlighting the continued reliance on surgeon preference.
- Coda RG, Cheema SG, Hermanns C, et al. (2021)
- ○ This study demonstrated marked variability in MPFL rehabilitation protocols, mirroring our findings. Notably, this persists even in MPFLR, widely considered the gold standard surgical treatment.
- Hysing Dahl T, Inderhaug E. (2024)
- ○ This review emphasizes individualized, phase based rehabilitation guided by functional criteria, while accounting for biological healing and psychological readiness for return to sport or activity.
- Morgan C, Bell RM, Burland JP, et al. (2022)
- ○ This study suggests that accelerated rehabilitation after TTO may be feasible, contrasting with the more conservative approaches commonly used in practice.
- Kung TH, Cheatham M, Medenilla A, et al. (2023)
- ○ This study showed that large language models can reproduce core medical knowledge. However, their application to real world clinical decision making remains limited.
Author contributions
MV and JS contributed to the study design, data collection, and drafting of this work; IYM contributed to statistical analysis, results interpretation, and drafting of this work; OCM and NK contributed to the data collection; RA and GR contributed to results interpretation and critically revised final draft; RG contributed to the study conceptualization, study design, results interpretation, and critically revised this work. All authors approved this version for publication and agreed to be accountable for all aspects of the work.
Funding
No external funding was received for this study.
Data Availability
The data supporting the findings of this study are derived from publicly available sources, including institutional rehabilitation protocols and published literature. All data used in this analysis are available within the article and its supplementary materials, and additional details can be obtained from the corresponding author upon reasonable request.
Declarations
Ethical Approval
Not applicable.
Informed consent
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Alaia MJ, Cohn RM, Strauss EJ. Patellar instability. Bull Hosp Jt Dis (2013). 2014;72(1):6–17. PubMed PMID: 25150323. [PubMed] [Google Scholar]
- 2.Dejour DH, Mazy D, Pineda T, Cance N, Dan MJ, Giovannetti de Sanctis E. Patellar instability: current approach. EFORT Open Rev. 2025;10(6):378–87. 10.1530/EOR-2025-0051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Redziniak DE, Diduch DR, Mihalko WM, Fulkerson JP, Novicoff WM, Sheibani-Rad S, et al. Patellar Instability JBJS. 2009;91(9):2264. [PubMed] [Google Scholar]
- 4.Bailey MEA, Metcalfe A, Hing CB, Eldridge J. Consensus guidelines for management of patellofemoral instability. Knee. 2021;29:305–12. 10.1016/j.knee.2021.02.018. [DOI] [PubMed] [Google Scholar]
- 5.Smith TO, Gaukroger A, Metcalfe A, Hing CB. Surgical versus non-surgical interventions for treating patellar dislocation - Smith, TO – 2023 | Cochrane Library [Internet]. [cited 2026 Apr 7]. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008106.pub4/full [DOI] [PMC free article] [PubMed]
- 6.Bernstein M, Bozzo I, Park P, Pauyo T. Patellofemoral instability Part II: surgical treatment. J Am Acad Orthop Surg. 2024;32(20):e1035-46. 10.5435/JAAOS-D-23-00650. [DOI] [PubMed] [Google Scholar]
- 7.Hurley ET, Sherman SL, Chahla J, Gursoy S, Alaia MJ, Tanaka MJ, et al. A modified Delphi consensus statement on patellar instability: Part II: medial patellofemoral ligament reconstruction, tibial tubercle osteotomy, trochleoplasty, rehabilitation, and return to sport. Bone Joint J. 2023;105-B(12):1265–70. 10.1302/0301-620X.105B12.BJJ-2023-0110.R1. [DOI] [PubMed] [Google Scholar]
- 8.Bernstein M, Bozzo I, Park P, Pauyo T. Patellofemoral instability Part II: surgical treatment. J Am Acad Orthop Surg. 2024;32(20):e1035. 10.5435/JAAOS-D-23-00650. [DOI] [PubMed]
- 9.Hysing-Dahl T, Inderhaug E. Rehabilitation after surgery for patellar instability. J Exp Orthop. 2024;11(3):e12062. 10.1002/jeo2.12062. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Coda RG, Cheema SG, Hermanns C, Kramer M, Tarakemeh A, Schroeppel JP, et al. Online rehabilitation protocols for medial patellofemoral ligament reconstruction with and without tibial tubercle osteotomy are variable among institutions. Arthrosc Sports Med Rehabil. 2021;3(2):e305-13. 10.1016/j.asmr.2020.09.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Lightsey HM, Wright ML, Trofa DP, Popkin CA, Ahmad CS, Redler LH. Rehabilitation variability following medial patellofemoral ligament reconstruction. Phys Sportsmed. 2018;46(4):441–8. 10.1080/00913847.2018.1487240. [DOI] [PubMed] [Google Scholar]
- 12.Lieber AC, Steinhaus ME, Liu JN, Hurwit D, Chiaia T, Strickland SM. Quality and variability of online available physical therapy protocols from academic orthopaedic surgery programs for medial patellofemoral ligament reconstruction. Orthop J Sports Med. 2019;7(7):2325967119855991. 10.1177/2325967119855991. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Ganley T. Children’s hospital of Philadelphia. Medial Patellofemoral Ligament Reconstruction Protocol [Internet]. 2023. Available from: https://www.chop.edu/sites/default/files/sports-medicine-patellofemoral-ligament-reconstruct.pdf
- 14.Clark D. Combined Medial Patello Femoral Ligament (MPFL) Reconstruction with Plate Assisted Tibial Tubercle Osteotomy plus Distalisation [Internet]. Available from: https://www.dcknee.com/wp-content/uploads/Damian-Clark-plate-assisted-tto.pdf
- 15.Díaz P, Colmenares O, Figueroa D. Corrección de La Altura Patelar En Inestabilidad Rotuliana. Revista Chil de Ortop y Traumatología. 2021;62(01):046–56. 10.1055/s-0040-1722239. [Google Scholar]
- 16.Hsu CJ, Lee C, Christensen RS, Liu TY. Current concept review: medial patellofemoral ligament reconstruction: from rehabilitation to return to sport. Int J Sports Phys Ther. 2025. 10.26603/001c.141128. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Marangoni LD, Bitar IJ, Bustos DG, Pezzutti L, Bitar LB, Rivera Bacile V, et al. Efecto de la reconstrucción del ligamento patelofemoral medial sobre la altura patelar en pacientes esqueléticamente inmaduros: análisis radiográfico y funcional. RELART. 2025;32(3):197–204. 10.63403/re.v32i3.444. [Google Scholar]
- 18.Morgan C, Bell RM, Burland JP, Kriscenski D, Ilinski A, Cote MP, et al. Effectiveness of an accelerated rehabilitation protocol after tibial tubercle osteotomy. Orthop J Sports Med. 2022;10(11):23259671221133105. 10.1177/23259671221133105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Reinholz AK, Till SE, Crowe MM, Hevesi M, Saris DBF, Stuart MJ et al. Grooveplasty Compared With Trochleoplasty for the Treatment of Trochlear Dysplasia in the Setting of Patellar Instability. Arthroscopy, Sports Medicine, and Rehabil. 2023;5(1). 10.1016/j.asmr.2022.11.020 [DOI] [PMC free article] [PubMed]
- 20.Maestu R, Medus M, Lamar Z, Rainaudi P, Batista J. Indicaciones y Complicaciones en la Reconstrucción del Ligamento Patelofemoral Medial. Artroscopia. 2019;26(4):113–7. [Google Scholar]
- 21.Masquijo JJ, Carabajal Mattar M. Inestabilidad patelofemoral en niños y adolescentes: revisión de conceptos actuales. Rev Asoc Arg Ort y Traumatol. 2024;89(4):403–15. 10.15417/issn.1852-7434.2024.89.4.1965. [Google Scholar]
- 22.Watson R, Sullivan B, Stone AV, Jacobs C, Malone T, Heebner N, et al. Lateral Patellar Dislocation: A Critical Review and Update of Evidence-Based Rehabilitation Practice Guidelines and Expected Outcomes. JBJS Reviews. 2022;10(5). 10.2106/JBJS.RVW.21.00159. [DOI] [PubMed]
- 23.Raney E, Onyeukwu C, Dvorsky J, Cunningham M, Hughes JD. Managing patellofemoral instability in in-season athletes: a review. Ann Joint. 2025;10:37–37. 10.21037/aoj-24-54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.guidelines PVL. Medial Patello-Femoral Ligament Reconstruction.2022 [Internet]. Available from: https://apps.nhslothian.scot/files/sites/2/MPFL-Guidelines-2022-1-1.pdf
- 25.clinic DPT. Medial Patellofemoral Ligament (MPFL) Reconstruction and Proximal Realignment [Internet]. Available from: https://bpb-us-w2.wpmucdn.com/sites.udel.edu/dist/c/3448/files/2016/01/Medial-Patellofemoral-Ligament-MPFL-Reconstruction-and-Proximal.pdf
- 26.Denton M. Medial patellofemoral ligament (MPFL) reconstruction rehabilitation guidelines using hamstring graft. In: Sheffield Children’s NHS Foundation Trust [Internet]. 2019. Available from: https://www.sheffieldchildrens.nhs.uk
- 27.Wulf C. Medial patellofemoral ligament (MPFL) repair and reconstruction rehabilitation protocol [Internet]. Available from: https://tcomn.com/wp-content/uploads/2014/08/MPFL-Reconstruction-2-13-13.pdf
- 28.Medicine HMBS. Medial Patellofemoral Ligament Reconstruction (MPFL [Internet]. 2019. Available from: https://banffsportmed.ca/wp-content/uploads/2019/09/MPFL-Post-Operative-Sept-2019-FINAL.pdf
- 29.Clark D. Medial Patellofemoral Ligament Reconstruction Adults and Pediatrics [Internet]. Available from: https://www.dcknee.com/wp-content/uploads/Damian-Clark-mpfl-reconstruction.pdf
- 30.Ingle A. Medial patellofemoral ligament reconstruction clinical practice guideline [Internet]. Ohio State University; 2015. Available from: https://wexnermedical.osu.edu/-/media/files/wexnermedical/patient-care/healthcare-services/sports-medicine/education/medical-professionals/knee-ankle-and-foot/medialpatellofemoralligamentreconstruction.pdf?la=en%3C/a
- 31.Ganley T. Medial Patellofemoral Ligament Reconstruction with Tibial Tubercle Osteotomy Protocol [Internet]. Children’s Hospital Philadelphia; 2023. Available from: https://www.chop.edu/sites/default/files/sports-medicine-patellofemoral-ligament-reconstruct-tibial.pdf.pdf
- 32.University OS. Medial patellofemoral ligament reconstruction-fulkerson procedure clinical practice guideline [Internet]. 2015. Available from: https://hrs.osu.edu/-/media/files/wexnermedical/patient-care/healthcare-services/sports-medicine/education/medical-professionals/knee-ankle-and-foot/mpflfulkerson.pdf?la=en&hash=FECB2EAB7E8AD74313129A56100873E993DB9D43
- 33.health UW. Medial Patellofemoral Ligament Repair and Reconstruction [Internet]. Available from: https://bynder.uwhealth.org/m/e3ea943ea984fc0e/original/Rehab-Guideline-Medial-Patellofemoral-Ligament-Repair-and-Reconstruction.pdf
- 34.Sarassa C, Carmona D, Vanegas D, Restrepo C, Herrera AM. Método para la reconstrucción del ligamento patelofemoral medial utilizando el tendón del cuádriceps: descripción de la técnica y resultados. Revista Colombiana de Ortopedia y Traumatología. 2020;34(1):33–8. 10.1016/j.rccot.2020.04.011. [Google Scholar]
- 35.Orthopedics U. MPFL Protocol [Internet]. Available from: https://universityorthopedics.com/assets/knee/MPFL-Reconstruction-Protocol.pdf
- 36.Frantz T. MPFL Reconstruction Physical Therapy Protocol [Internet]. Available from: https://www.sportsmedindiana.com/pdf/mpfl-reconstruction.pdf
- 37.Island OR. MPFL Reconstruction Protocol [Internet]. Available from: https://www.orthopedicsri.com/wp-content/uploads/2024/07/ORI_Post-Op_Rehab_Protocols_MPFLReconstruction.pdf
- 38.Owusu-Akyaw K. MPFL Reconstruction Rehabilitation [Internet]. Available from: https://www.orthovirginia.com/wp-content/uploads/2022/04/Owusu-Akyaw-Medial-Patellofemoral-Ligament-Reconstruction-Protocol.pdf
- 39.Sanford, MPFL Reconstruction Rehabilitation Guideline [Internet]. 2024. Available from: https://www.sanfordhealth.org/-/media/org/files/medical-professionals/resources-and-education/mpfl-reconstruction-rehabilitation-guideline.pdf
- 40.Posner M. MPFL reconstruction rehabilitation guidelines [Internet]. 2020. Available from: https://www.matthewposnermd.com/pdf/mpfl-reconstruction-rehabilitation-guidelines.pdf
- 41.Parker A. MPFL Reconstruction with Tibial Tubercle Osteotomy Physical Therapy Protocol [Internet]. Available from: https://www.parkerorthopedics.com/pdfs/mpfl-reconstruction-with-tibial-tubercle-osteotomy.pdf
- 42.Hip M. Knee. MPRFL Rehabilitation guideline [Internet]. Available from: https://www.melbournehipandknee.com.au/pdf/mpfl-rehabilitation-protocol.pdf
- 43.Firman E. Osteotomía de la TAT combinada con reconstrucción del ligamento patelofemoral medial en pacientes con luxación recidivante de rótula. RELART. 2025;32(1):20–8. 10.63403/re.v32i1.380. [Google Scholar]
- 44.Westmead CH. Patella Dislocation - Physiotherapy management - CHW [Internet]. 2022. Available from: https://resources.schn.health.nsw.gov.au/policies/policies/pdf/2022-137.pdf
- 45.orthopedics D. Patellar stabilization rehabilitation protocol [Internet]. 2016. Available from: https://cdn.dal.ca/content/dam/dalhousie/pdf/faculty/medicine/departments/department-sites/surgery/divisions/orthopaedic-surgery/coady/2016%20Patellar%20Stabilization%20Rehab.pdf
- 46.Orthopaedics Y. Post-operative medial patellofemoral ligament (MPFL) reconstruction protocol [Internet]. Available from: https://yorkorthopaedics.co.uk/downloads/MPFL%20Protocol%202024.pdf
- 47.Health UVA. Post-operative Rehabilitation Protocol Medial Patellofemoral Ligament (MPFL) Reconstruction [Internet]. Available from: https://med.virginia.edu/orthopaedic-surgery/wp-content/uploads/sites/242/2021/06/MPFL-Reconstruction.pdf
- 48.Orthopedic CSM. Post-operative Rehabilitation Protocol Medial Patellofemoral Ligament (MPFL) Reconstruction WITH TTO [Internet]. Available from: https://sa1s3.patientpop.com/assets/docs/322079.pdf
- 49.Mithoefer K. Postoperative Rehabilitation Guidelines Medial Patellofemoral Ligament Reconstruction [Internet]. Available from: https://www.bostonjointpreservation.com/pdfs/mpfl-reconstruction.pdf
- 50.M CN. Propuesta de protocolo de tratamiento fisioterápico tras la reconstrucción del ligamento patelofemoral medial en la luxación recidivante de rótula: a propósito de un caso clínico [thesis [Internet]. Salamanca: Facultad de Enfermería y Fisioterapia; 2020. Available from: https://gredos.usal.es/bitstream/handle/10366/143705/TFG_CallejaNicolas_Ligamento.pdf?sequence=1&isAllowed=y
- 51.McGee TG, Cosgarea AJ, McLaughlin K, Tanaka M, Johnson K. Rehabilitation after medial patellofemoral ligament reconstruction. Sports Medicine and Arthroscopy Review. 2017;25(2):105–13. 10.1097/JSA.0000000000000147. [DOI] [PubMed] [Google Scholar]
- 52.Hysing-Dahl T, Inderhaug E. Rehabilitation after surgery for patellar instability. J exp orthop. 2024;11(3):e12062. 10.1002/jeo2.12062. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Lampros RE, Wiater AL, Tanaka MJ. Rehabilitation and return to sport after Medial Patellofemoral Complex Reconstruction. Arthrosc Sports Med Rehabil. 2022. 10.1016/j.asmr.2021.09.030. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Manske RC, Prohaska D. Rehabilitation following medial patellofemoral ligament reconstruction for patellar instability. Int J Sports Phys Ther. 2017;12(3):494–511. [PMC free article] [PubMed] [Google Scholar]
- 55.Smith B. Rehabilitation Protocol for Medial Patellofemoral Ligament Reconstruction [Internet]. Available from: https://www.bradleysmithmd.com/pdf/rehab-mpfl-reconstruction.pdf
- 56.Brigham MG. Rehabilitation Protocol for MPFL Reconstruction [Internet]. 2024. Available from: https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/sports-medicine/physical-therapy/rehabilitation-protocol-for-MPFL.pdf
- 57.Smith B. Rehabilitation Protocol for Tibial Tubercle Osteotomy [Internet]. Available from: https://www.bradleysmithmd.com/pdf/rehab-tibial-tubercle-osteotomy-upd.pdf
- 58.Watson J. Rehabilitation protocol- MPFL Reconstruction [Internet]. Available from: https://www.jonwatsonmd.com/pdfs/pt-protocols/pt-mpfl.pdf
- 59.Watson J. Rehabilitation protocol-Tibial tubercle osteotomy [Internet]. Available from: https://www.jonwatsonmd.com/pdfs/pt-protocols/pt-tto.pdf
- 60.Chatterji R, White AE, Hadley CJ, Cohen SB, Freedman KB, Dodson CC. Return-to-play guidelines after patellar instability surgery requiring bony realignment: a systematic review. Orthopaedic Journal of Sports Medicine. 2020;8(12):2325967120966134. 10.1177/2325967120966134. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Saper MG, Fantozzi P, Bompadre V, Racicot M, Schmale GA. Return-to-sport testing after medial patellofemoral ligament reconstruction in adolescent athletes. Orthopaedic Journal of Sports Medicine. 2019;7(3):2325967119828953. 10.1177/2325967119828953. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 62.c K. Tibial Tubercle Anteromedial (Fulkerson) Osteotomy Physical Therapy Protocol [Internet]. 2016. Available from: https://www.orthoindy.com/wp-content/uploads/Tibial-Tubercle-Anteromedial-Fulkerson-Osteotomy.pdf
- 63.Tauberg B. Tibial Tubercle Osteotomy Rehab Protocol [Internet]. Available from: https://www.brandontaubergmd.com/pdfs/tto-mpfl-upd-new.pdf
- 64.Society MPTBP. Tibial Tubercle Osteotomy with Screw Fixation [Internet]. Available from: https://bpfsoc.com/wp-content/uploads/Tibial-Tubercle-Osteotomy-with-Screw-Fixation.pdf
- 65.Owusu-Akyaw K. Tibial Tubercle Realignment Rehabilitation [Internet]. Available from: https://www.orthovirginia.com/wp-content/uploads/2022/04/Owusu-Akyaw-Tibial-Tubercle-Realignment-Protocol.pdf
- 66.Clark D. Trochleoplasty [Internet]. Available from: https://www.dcknee.com/wp-content/uploads/Damian-Clark-trochleoplasty.pdf
- 67.Ohio State University B, TROCHLEOPLASTY [Internet]. 2024. Available from: https://hrs.osu.edu/-/media/files/wexnermedical/patient-care/healthcare-services/sports-medicine/education/medical-professionals/knee-ankle-and-foot/trochleoplasty.pdf?la=en&hash=9419B2F0453DDAA33BDCD789F6C21CFCD07A9758
- 68.McNicholas M. Trochleoplasty (+/- MPFL Reconstruction +/- Osteotomy) Protocol [Internet]. 2020. Available from: https://mcnicholaskneeclinic.co.uk/wp-content/uploads/2020/11/19.-Trochleoplasty-MPFL-Rconstruction-Osteotomy-Protocol.pdf
- 69.Boden S. Trochleoplasty + Tibial Tubercle Osteotomy (TTO) + MPFL Reconstruction Rehabilitation Protocol [Internet]. Available from: https://www.bodenorthopedics.com/wp-content/uploads/2025/06/Trochleoplasty-TTO-MPFL-Reconstruction.pdf
- 70.Hip M. Knee. Trochleoplasty Rehabilitation guideline [Internet]. Available from: https://www.melbournehipandknee.com.au/pdf/trochleoplasty-rehabilitation-protocol-new.pdf
- 71.Mayo B. Trochleoplasty with MPFL Reconstruction [Internet]. 2024. Available from: https://www.benmayomd.com/wp-content/uploads/2025/02/Trochleoplasty-MPFL-Reconstruction-Rehab-Protocol.pdf
- 72.Morgan C, Bell RM, Burland JP, Kriscenski D, Ilinski A, Cote MP, et al. Effectiveness of an accelerated rehabilitation protocol after tibial tubercle osteotomy. Orthopaedic Journal of Sports Medicine. 2022;10(11):23259671221133105. 10.1177/23259671221133105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 73.Hurley ET, Markus DH, Mannino BJ, Gonzalez-Lomas G, Alaia MJ, Campbell KA, et al. Patients unable to return to play following medial patellofemoral ligament reconstructions demonstrate poor psychological readiness. Knee Surg Sports Traumatol Arthrosc. 2021;29(11):3834–8. 10.1007/s00167-021-06440-y. [DOI] [PubMed] [Google Scholar]
- 74.Kung TH, Cheatham M, Medenilla A, Sillos C, De Leon L, Elepaño C, et al. Performance of ChatGPT on USMLE: potential for AI-assisted medical education using large language models. PLOS Digit Health. 2023;2(2):e0000198. 10.1371/journal.pdig.0000198. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 75.Liu M, Okuhara T, Chang X, Okada H, Kiuchi T. Performance of ChatGPT in medical licensing examinations in countries worldwide: a systematic review and meta-analysis protocol. PLoS One. 2024;19(10):e0312771. 10.1371/journal.pone.0312771. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are derived from publicly available sources, including institutional rehabilitation protocols and published literature. All data used in this analysis are available within the article and its supplementary materials, and additional details can be obtained from the corresponding author upon reasonable request.