Tag Archive for: Rehabilitation

Jill Monson, Elizabeth Niemuth

Volume 3 | Issue 1 | Jan – Apr 2018 | Page 36-41

Author: Jill Monson [1], Elizabeth Niemuth [2]

[1] Department of Physical Therapy, TRIA Woodbury, 155 Radio Drive, Woodbury, MN 55125, USA,
[2] Department of Physical Therapy, Institute for Athletic Medicine, M Health Clinics and Surgery Center, Minneapolis, MN 55455, USA

Address of Correspondence
Dr. Elizabeth Niemuth,
Institute for Athletic Medicine, M Health Clinics and Surgery Center, 909 Fulton Street SE, Minneapolis, MN 55455, USA.
Email: eniemut1@fairview.org


The rehabilitation process after surgical intervention for patellar instability warrants special consideration of the anatomy, biomechanics, and surgical procedure to facilitate the best outcomes for the patient. There is a paucity of evidence-based literature regarding post-operative rehabilitation protocols for the patellofemoral (PF) compartment. Recommendations for early rehabilitation (0–6 weeks) after lateral retinacular lengthening, medial PF ligament reconstruction, tibial tubercle osteotomy, and trochleoplastyare reviewed in this article. For each procedure, the following common post-operative rehabilitation focus points are reviewed: Weight-bearing status and brace use, joint range of motion, and strengthening.
Keywords: Patellofemoral, Rehabilitation, Patellar instability.


1. Ward SR, Powers CM. The influence of patella alta on patellofemoral joint stress during normal and fast walking. ClinBiomech (Bristol, Avon) 2004;19:1040-7.
2. Powers CM. Patellar kinematics, part I: The influence of vastus muscle activity in subjects with and without patellofemoral pain. PhysTher 2000;80:956-64.
3. Kaya D, Citaker S, Kerimoglu U, Atay OA, Nyland J, Callaghan M, et al. Women with patellofemoral pain syndrome have quadriceps femoris volume and strength deficiency. Knee Surg Sports Traumatol Arthrosc 2011;19:242-7.
4. Grenholm A, Stensdotter AK, Häger-Ross C. Kinematic analyses during stair descent in young women with patellofemoral pain. Clin Biomech (Bristol, Avon) 2009;24:88-94.
5. HeinoBrechter J, Powers CM. Patellofemoral stress during walking in persons with and without patellofemoral pain. Med Sci Sports Exerc 2002;34:1582-93.
6. Brechter JH, Powers CM. Patellofemoral joint stress during stair ascent and descent in persons with and without patellofemoral pain. Gait Posture 2002;16:115-23.
7. Spencer JD, Hayes KC, Alexander IJ. Knee joint effusion and quadriceps reflex inhibition in man. Arch Phys Med Rehabil 1984;65:171-7.
8. Pietrosimone B, Lepley AS, Murray AM, Thomas AC, Bahhur NO, Schwartz TA, et al. Changes in voluntary quadriceps activation predict changes in muscle strength and gait biomechanics following knee joint effusion. Clin Biomech (Bristol, Avon) 2014;29:923-9.
9. Senavongse W, Farahmand F, Jones J, Andersen H, Bull AM, Amis AA, et al. Quantitative measurement of patellofemoral joint stability: Force-displacement behavior of the human patella in vitro. J Orthop Res 2003;21:780-6.
10. Amis AA. Current conceptson anatomy and biomechanics of patellar stability. Sports Med Arthrosc Rev 2007;15:48-56.
11. Desio SM, Burks RT, Bachus KN. Soft tissue restraints to lateral patellar translation in the human knee. Am J Sports Med 1998;26:59-65.
12. Conlan T, Garth WP Jr., Lemons JE. Evaluation of the medial soft-tissue restraints of the extensor mechanism of the knee. J Bone Joint Surg Am1993;75:682-93.
13. Hautamaa PV, Fithian DC, Kaufman KR, Daniel DM, Pohlmeyer AM. Medial soft tissue restraints in lateral patellar instability and repair. ClinOrthopRelat Res 1998;349:174-82.
14. Mountney J, Senavongse W, Amis AA, Thomas NP. Tensile strength of the medial patellofemoral ligament before and after repair or reconstruction. J Bone Joint Surg Br2005;87:36-40.
15. Duchman KR, DeVries NA, McCarthy MA, Kuiper JJ, Grosland NM, Bollier MJ, et al. Biomechanical evaluation of medial patellofemoral ligament reconstruction. Iowa Orthop J 2013;33:64-9.
16. Woo SL, Gomez MA, Sites TJ, Newton PO, Orlando CA, Akeson WH, et al. The biomechanical and morphological changes in the medial collateral ligament of the rabbit after immobilization and remobilization. J Bone Joint Surg Am 1987;69:1200-11.
17. Newton PO, Woo SL, Kitabayashi LR, Lyon RM, Anderson DR, Akeson WH, et al.Ultrastructural changes in knee ligaments following immobilization. Matrix 1990;10:314-9.
18. Smith TO, Russell N, Walker J. A systematic review investigating the early rehabilitation of patients following medial patellofemoral ligament reconstruction for patellar instability. Crit Rev PhysRehabil Med2007;19:79-95.
19. Doucette SA, Child DD. The effect of open and closed chain exercise and knee joint position on patellar tracking in lateral patellar compression syndrome. J Orthop Sports Phys Ther 1996;23:104-10.
20. Steinkamp LA, Dillingham MF, Markel MD, Hill JA, Kaufman KR. Biomechanical considerations in patellofemoral joint rehabilitation. Am J Sports Med 1993;21:438-44.
21. Powers CM, Ward SR, Fredericson M, Guillet M, Shellock FG. Patellofemoral kinematics during weight-bearing and non-weight-bearing knee extension in persons with lateral subluxation of the patella: A preliminary study. J Orthop Sports Phys Ther 2003;33:677-85.
22. Powers CM, Ho KY, Chen YJ, Souza RB, Farrokhi S. Patellofemoral joint stress during weight-bearing and non-weight-bearing quadriceps exercises. J Orthop Sports PhysTher 2014;44:320-7.
23. Escamilla RF, Zheng N, Macleod TD, Edwards WB, Imamura R, Hreljac A, et al. Patellofemoral joint force and stress during the wall squat and one-leg squat. Med Sci Sports Exerc 2009;41:879-88.
24. Lee TQ, Morris G, Csintalan RP. The influence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther 2003;33:686-93.
25. Huberti HH, Hayes WC. Patellofemoral contact pressures. The influence of Q-angle and tendofemoral contact. J Bone Joint Surg [Am] 1984;66:715-24.
26. Li G, DeFrate LE, Zayontz S, Park SE, Gill TJ. The effect of tibiofemoral joint kinematics on patellofemoral contact pressures under simulated muscle loads. J Orthop Res 2004;22:801-6.
27. Davis K, Caldwell P, Wayne J, Jiranek WA. Mechanical comparison of fixation techniques for the tibial tubercle osteotomy. ClinOrthopRelat Res 2000;380:241-9.
28. Caldwell PE, Bohlen BA, Owen JR, Brown MH, Harris B, Wayne JS, et al. Dynamic confirmation of fixation techniques of the tibial tubercle osteotomy. Clin Orthop Relat Res 2004;424:173-9.
29. Powers CM, Lilley JC, Lee TQ. The effects of axial and multi-plane loading of the extensor mechanism on the patellofemoral joint. Clin Biomech (Bristol, Avon) 1998;13:616-24.
30. Rathleff MS, Rathleff CR, Crossley KM, Barton CJ. Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis. Br J Sports Med 2014;48:1088.
31. Van Cant J, Pineux C, Pitance L, Feipel V. Hip muscle strength and endurance in females with patellofemoral pain: A systematic review with meta-analysis. Int J Sports Phys Ther 2014;9:564-82.
32. Crossley KM, van Middelkoop M, Callaghan MJ, Collins NJ, Rathleff MS, Barton CJ, et al. 2016 patellofemoral pain consensus statement from the 4th international patellofemoral pain research retreat, manchester. Part 2: Recommended physical interventions (exercise, taping, bracing, foot orthoses and combined interventions). Br J Sports Med 2016;50:844-52.

How to Cite this article:. Monson J, Niemuth E. Post-operative Rehabilitation for Select Patellar-stabilizing Procedures. Asian Journal of Arthroscopy Jan – April 2018;3(1):36-41.

(Abstract)      (Full Text HTML)      (Download PDF)

Shyam Sundar, David V Rajan

Volume 2 | Issue 1 | Jan – Apr 2017 | Page 40 – 48

Author: Shyam Sundar [1], David V Rajan [1].

[1] Ortho OneOrthopaedic Speciality Centre, Coimbatore, Tamil Nadu, India

Address of Correspondence

Dr. Shyam Sundar,
MS Orthopaedics, Ortho One Orthopaedic Speciality Centre, Coimbatore – 641 005, Tamil Nadu, India.
Email: drshyam.msortho@gmail.com


The shoulder joint is a polyaxial joint with the advantage of increased mobility at the cost of stability. The incidence of subluxation/dislocation is on the increase considering the fact that children are more actively involved in sporting activities at a very young age. This has necessitated the orthopedic surgeons to identify those at risk of injuries as well as to treat those with injuries to restore normality without compromising the function. Over the recent past, surgical management for shoulder instability has evolved to a more precise level giving importance to the minutest details in respecting and repairing the injured structures. As a result of which the patient’s recovery and functional outcome has been better than how it was earlier. Nonetheless, the success of surgery depends not only on the surgeon or the patient factors but also in the implementation of a tailored rehabilitation protocol focusing on getting the patient back to normalcy at the earliest with minimal discomfort. The aim of this article is to kindle the various aspects of an ideal rehabilitation following surgical stabilization of shoulder instability and to guide in the optimizing treatment protocol.
Keywords: Shoulder instability, Rehabilitation, Proprioception, Kinetic chain.


1. Kim SH, Ha KI, Jung MW, Lim MS, Kim YM, Park JH. Accelerated rehabilitation after arthroscopic Bankart repair for selected cases: A prospective randomized clinical study. Arthroscopy 2003;19(7):722-731.
2. Itoi E, Hsu HC, An KN. Biomechanical investigation of the glenohumeral joint. J Shoulder Elbow Surg 1996;5(5):407-424.
3. Abboud JA, Soslowsky LJ. Interplay of the static and dynamic restraints in glenohumeral instability. ClinOrthopRelat Res 2002;400:48-57.
4. Itoi E. Pathophysiology and treatment of atraumatic instability of the shoulder. J OrthopSci 2004;9(2):208-213.
5. Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med 1994;22(5):589-594.
6. Hawkins RH, Hawkins RJ. Failed anterior reconstruction for shoulder instability. J Bone Joint Surg Br 1985;67(5):709-714.
7. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am 1996;78(11):1677-1684.
8. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study. J Bone Joint Surg Am 2000;82(1):35-46.
9. Robinson CM, Kelly M, Wakefield AE. Redislocation of the shoulder during the first six weeks after a primary anterior dislocation: Risk factors and results of treatment. J Bone Joint Surg Am 2002;84-A(9):1552-1559.
10. Rowe CR, Pierce DS, Clark JG. Voluntary dislocation of the shoulder. A preliminary report on a clinical, electromyographic, and psychiatric study of twenty-six patients. J Bone Joint Surg Am 1973;55(3):445-460.
11. Weber BG, Simpson LA, Hardegger F. Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion. J Bone Joint Surg Am 1984;66(9):1443-1450.
12. Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am 2006;88(11):2326-2336.
13. Hintermann B, Gächter A. Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995;23(5):545-551.
14. Anakwenze OA, Hsu JE, Abboud JA, Levine WN, Huffman GR. Recurrent anterior shoulder instability associated with bony defects. Orthopedics 2011;34(7):538-544.
15. Provencher MT, Frank RM, Leclere LE, Metzger PD, Ryu JJ, Bernhardson A, et al.The Hill-Sachs lesion: Diagnosis, classification, and management. J Am AcadOrthopSurg 2012;20(4):242-252.
16. Skendzel JG, Sekiya JK. Diagnosis and management of humeral head bone loss in shoulder instability. Am J Sports Med 2012;40(11):2633-2644.
17. Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med 1997;25(3):306-311.
18. Bigliani LU, Newton PM, Steinmann SP, Connor PM, Mcllveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med 1998;26(1):41-45.
19. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am 2003;85-A(5):878-884.
20. Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic stabilization in patients with an inverted pear glenoid: Results in patients with bone loss of the anterior glenoid. Am J Sports Med 2007;35(8):1276-1283.
21. Sterling M, Jull G, Wright A. The effect of musculoskeletal pain on motor activity and control. J Pain 2001;2(3):135-145.
22. Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, et al.A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study. J Shoulder Elbow Surg 2003;12(5):413-415.
23. Miller BS, Sonnabend DH, Hatrick C, O’leary S, Goldberg J, Harper W, et al. Should acute anterior dislocations of the shoulder be immobilized in external rotation? A cadaveric study. J Shoulder Elbow Surg 2004;13(6):589-592.
24. McMahon PJ, Lee TQ. Muscles may contribute to shoulder dislocation and stability. ClinOrthopRelat Res 2002;403 Suppl:S18-S25.
25. McAuliffe TB, Pangayatselvan T, Bayley I. Failed surgery for recurrent anterior dislocation of the shoulder. Causes and management. J Bone Joint Surg Br 1988;70(5):798-801.
26. Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br 2007;89(11):1470-1477.
27. Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: From “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy 2014;30(1):90-98.
28. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-sachs “remplissage”: An arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy 2008;24(6):723-726.
29. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16(7):677-694.
30. Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: An indicator of significant glenoid bone loss. Arthroscopy 2004;20(2):169-174.
31. Fedorka CJ, Mulcahey MK. Recurrent anterior shoulder instability: A review of the Latarjet procedure and its postoperative rehabilitation. PhysSportsmed 2015;43(1):73-79.
32. Frostick SP, Sinopidis C, Al Maskari S, Gibson J, Kemp GJ, Richmond JC. Arthroscopic capsular shrinkage of the shoulder for the treatment of patients with multidirectional instability: Minimum 2-year follow-up. Arthroscopy 2003;19(3):227-233.
33. Bigliani LU, Pollock RG, McIlveen SJ, Endrizzi DP, Flatow EL. Shift of the posteroinferior aspect of the capsule for recurrent posterior glenohumeral instability. J Bone Joint Surg Am 1995;77(7):1011-1020.
34. Antoniou J, Duckworth DT, Harryman DT 2nd. Capsulolabral augmentation for the the management of posteroinferior instability of the shoulder. J Bone Joint Surg Am 2000;82(9):1220-1230.
35. Pollock RG, Bigliani LU. Recurrent posterior shoulder instability. Diagnosis and treatment. ClinOrthopRelat Res 1993;291:85-96.
36. Wirth MA, Groh GI, Rockwood CA Jr. Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder. J Bone Joint Surg Am 1998;80(11):1570-1578.
37. Kim SH, Ha KI, Yoo JC, Noh KC. Kim’s lesion: An incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy 2004;20(7):712-720.
38. Inman VT, Saunders JB, Abbott LC. Observations of the function of the shoulder joint 1944. ClinOrthopRelat Res 1996;330:3-12.
39. Wilk KE, Arrigo C. Current concepts in the rehabilitation of the athletic shoulder. J Orthop Sports PhysTher 1993;18(1):365-378.
40. Bowen MK, Warren RF. Ligamentous control of shoulder stability based on selective cutting and static translation experiments. Clin Sports Med 1991;10(4):757-782.
41. O’Brien SJ, Neves MC, Arnoczky SP, Rozbruck SR, Dicarlo EF, Warren RF, et al. The anatomy and histology of the inferior glenohumeral ligament complex of the shoulder. Am J Sports Med 1990;18(5):449-456.
42. Cain PR, Mutschler TA, Fu FH, Lee SK. Anterior stability of the glenohumeral joint. A dynamic model. Am J Sports Med 1987;15(2):144-148.
43. Riemann BL, Lephart SM. The sensorimotor system, part I: The physiologic basis of functional joint stability. J Athl Train 2002;37(1):71-79.
44. Vangsness CT Jr, Ennis M, Taylor JG, Atkinson R. Neural anatomy of the glenohumeral ligaments, labrum, and subacromial bursa. Arthroscopy 1995;11(2):180-184.
45. Rossi A, Grigg P. Characteristics of hip joint mechanoreceptors in the cat. J Neurophysiol 1982;47(6):1029-1042.
46. Pedersen J, Lönn J, Hellström F, Djupsjöbacka M, Johansson H. Localized muscle fatigue decreases the acuity of the movement sense in the human shoulder. Med Sci Sports Exerc 1999;31(7):1047-1052.
47. Johansson H, Sjölander P, Sojka P. A sensory role for the cruciate ligaments. ClinOrthopRelat Res 1991;268:161-178.
48. Dietz V, Noth J, Schmidtbleicher D. Interaction between pre-activity and stretch reflex in human triceps brachii during landing from forward falls. J Physiol 1981;311:113-125.
49. Smith RL, Brunolli J. Shoulder kinesthesia after anterior glenohumeral joint dislocation. PhysTher 1989;69(2):106-112.
50. Tibone JE, Fechter J, Kao JT. Evaluation of a proprioception pathway in patients with stable and unstable shoulders with somatosensory cortical evoked potentials. J Shoulder Elbow Surg 1997;6(5):440-443.
51. Carpenter JE, Blasier RB, Pellizzon GG. The effects of muscle fatigue on shoulder joint position sense. Am J Sports Med 1998;26(2):262-265.
52. Lephart SM, Henry TJ. Functional rehabilitation for the upper and lower extremity. OrthopClin North Am 1995;26(3):579-592.
53. Davies GJ, Dickoff-Hoffman S. Neuromuscular testing and rehabilitation of the shoulder complex. J Orthop Sports PhysTher 1993;18(2):449-458.
54. Cavagna GA, Dusman B, Margaria R. Positive work done by a previously stretched muscle. J ApplPhysiol 1968;24(1):21-32.
55. Kibler WB, Wilkes T, Sciascia A. Mechanics and pathomechanics in the overhead athlete. Clin Sports Med 2013;32(4):637-651.
56. Sciascia A, Thigpen C, Namdari S, Baldwin K. Kinetic chain abnormalities in the athletic shoulder. Sports Med Arthrosc 2012;20(1):16-21.
57. McMullen J, Uhl TL. A kinetic chain approach for shoulder rehabilitation. J Athl Train 2000;35(3):329-337.
58. Kibler WB, Sciascia A, Thomas SJ. Glenohumeral internal rotation deficit: Pathogenesis and response to acute throwing. Sports Med Arthrosc 2012;20(1):34-38.
59. Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. J Orthop Sports PhysTher 2005;35(4):227-238.

How to Cite this article:. Sundar S, Rajan DV. Rehabilitation Postsurgical Stabilization for Shoulder Instability Asian Journal of Arthroscopy Jan – April 2017;1(2):40-48.


(Abstract)      (Full Text HTML)      (Download PDF)