Patellofemoral Dysfunction

Evidence-based
Clinical Protocols
2) Patellofemoral Dysfunction
CLINICAL EDITORS
Morgan Boyle, III, MEd, ATC
Steve Jacoby, ATC
EDITOR
Terry McLaughlin, MS, ATC
CONTRIBUTORS
Tab Blackburn, PT, ATC
Terry Giove, PT
Woody Goffinett, ATCs
Steve Hoffman, PT, ATC
Drew Hurley, ATC/L
Ginger Kurmann, PT, ATC
Terry Malone, PT, ATC
John Stemm, MEd, PT, ATC
Sarah Sydor, ATC
Steve Tippett, PT, ATC
Kim VanFleet, MS, ATC/L
Michael Voight, PT, ATC
Gary Wilkerson, Ed.D, ATC
FN: 03-027

INTRODUCTION........................................................................................................................................................................2-1
REHABILITATION GOAL................................................................................................................................................2-2
REHABILITATION PROGRAM CONSIDERATIONS............................................................................................................2-2
DEFINITIONS...............................................................................................................................................................2-2
POST-INJURY/PRE-SURGERY PHASE
GOALS (To progress to Phase I) ...................................................................................................................................2-3
PHASE I: Reduction of Acute Symptoms
GOALS (To progress to Phase II)...................................................................................................................................2-3
CLINICAL EVALUATION................................................................................................................................................2-3
CLINICAL TREATMENT OPTIONS ..................................................................................................................................2-5
SUPERVISED PROGRAM...............................................................................................................................................2-7
HOME PROGRAM .......................................................................................................................................................2-8
REPORTS.....................................................................................................................................................................2-8
PHASE II: Range of Motion and Initial Strengthening
GOALS (To progress to Phase III)..................................................................................................................................2-9
CLINICAL EVALUATION..............................................................................................................................................2-10
CLINICAL TREATMENT OPTIONS ................................................................................................................................2-11
SUPERVISED PROGRAM.............................................................................................................................................2-13
HOME PROGRAM .....................................................................................................................................................2-14
REPORTS...................................................................................................................................................................2-14
PHASE III: Initial Weight-bearing and Intermediate Strengthening
GOALS (To progress to Phase IV) ...............................................................................................................................2-15
HOME PROGRAM .....................................................................................................................................................2-21
REPORTS...................................................................................................................................................................2-22
PHASE IV: Return to Activity
GOALS......................................................................................................................................................................2-23
HOME PROGRAM .....................................................................................................................................................2-29
REPORTS...................................................................................................................................................................2-30
STABILITY INDEX.....................................................................................................................................................................2-31
REFERENCES...........................................................................................................................................................................2-33
© BIODEX MEDICAL SYSTEMS, INC.
EVIDENCE-BASED CLINICAL
PROTOCOL FOR
REHABILITATION OF
PATELLOFEMORAL DYSFUNCTION
table of contents

INTRODUCTION clinical protocol
The information contained in this manual is presented by Biodex Medical Systems as part of our commitment to provide
continuing service to medical professionals and to the community at large.
IMPORTANT: READ BEFORE PROCEEDING
Suggested courses of rehabilitation for any specific conditions are meant as references of generalized program models, and are not
intended as precise prescriptions for individual treatment. The data is a compilation of information based on the work of acknowl-
edged experts that have been published in respected journals.
We believe it is representative of current trends in scientifically derived and clinically proven principles and methods of rehabilitation
medicine. Much of the published information that we review, however, is based on research and case studies involving very specif-
ic patient or test subject populations. Many research subjects, for instance, are highly-trained and well conditioned athletes prior to
treatment, or are chosen because they have no known medical problems other than the condition involved in the study. It should
therefore be noted that the application of any published methods should be done with extreme care and should be based on
sound clinical judgment after thorough evaluation of the individual patient’s capabilities, limitations, and overall medical condition.
In the presence of any doubt, or question, regarding the efficacy of initiating a procedure, seek advise from appropriate sources
and/or consult with the patient’s physician.
Please send any comments or concerns to:
c/o Clinical Education
Biodex Medical Systems, Inc.
20 Ramsay Rd.
Shirley, NY 11967-4704
A special thanks goes to Terry McLaughlin, MS, ATC, Steven Jacoby, ATC and Morgan Boyle III, MEd, ATC, for their assistance in the
organization of this protocol.
© BIODEX MEDICAL SYSTEMS, INC. 2-1

2-2 INTRODUCTION
REHABILITATION PROGRAM CONSIDERATIONS:
To successfully rehabilitate the patient with patellofemoral dysfunction the therapy team must understand:
• Basic anatomy and function of the patellofemoral joint and associated structures
• Mechanism of injuries
• Healing process following initial injury
• Methods to optimize:
Patient compliance (assess potential; establish realistic goals)
Reduction of pain and edema
Increases in ROM
Increases in strength, power, and endurance
Improvement of agility (balance; proprioception)
• Appropriate allocations of resources and time to individual patient program
• Means of evaluating individual and overall program effectiveness
DEFINITIONS:
Goals: Specific improvements which must be met in order for patient to progress to next phase.
Clinical Evaluation: Evaluations that are only to be performed by certified and/or licensed ATC, PT or OT, in association with
supervising physician’s diagnosis.
Clinical Treatment Options: Treatment options that should only be performed under the supervision of certified and/or licensed clinicians.
Supervised Program: Rehabilitation program that should be done only under the direction of appropriately qualified personnel (i.e.
Certified Strength and Conditioning Specialist).
Home Program: Rehabilitation program that after proper instruction by supervising clinician, can be done by patient without supervision.
Reports: Test reports are to be completed at the end of each phase to ensure progress to the next phase is indicated.

PHASE I
GOALS:
• Mentally prepare patient for rehabilitation
• Education of patient to understand the problems of PF dysfunction
• Identify specific needs of patient and potential problems
• Restore normal flexibility
• Decrease joint effusion 4
• Maintain ankle ROM and strength
• Full knee PROM
• Decrease pain at rest to 0*
*Analog pain scale of 0-10
• Normalize gait deviations and correct biomechanical faults
Step Symmetry
• Identify contributory factors to condition
Vastus Medialis (VMO): Vastus Lateralis (VL)
• Increase VMO:VL strength ratio to 50%
• OKC Proprioception < 40% deficit bilaterally
Open Kinetic Chain (OKC)
• Isometric strength:
QUAD < 30% deficit
HAM < 30% deficit
• Stability Index*:
70% of Normative value for bilateral stance
*Note: See page 36 for normative values
CLINICAL EVALUATION:
• General patient history and observation
• Pain scale: 19
Severity, location, duration, quality, radiation
• Edema:
Degree and character of swelling
Patella ballottement test; mid-patella circumferential measurement
• Active and Passive range of motion
• Patella assessment:
Physical exam palpation and radiographs
reduction of acute symptoms

CLINICAL EVALUATION (CONT):
• Neurological assessment:
Myotomes, dermatomes and reflexes for L2 – S1
• Clinical tests:
Supine hamstring flexibility measurement
Ober test (IT Band tightness) 21
Thomas test (Rectus femoris tightness)
Plica test
• Palpation/Observation: 17
Identify VMO dysplasia
Biofeedback ratio
• Goniometry: 12
Knee flexion/extension (0-135º knee flexion) active and passive
• Patella assessment/mobility:
Radiological: Patella alto (congenital formation) Insall and Salvati method, independent of the knee flexion angle, the
length of the patella tendon should be equal to the longest (diagonal) length of the patella ligament. Patella baja (post
surgical condition). 13
Palpable: Tested with knee flexion at 30º-45º of knee flexion over a pillow or examiners knee. The patella should glide
one half its width medially & laterally. 14
Physical: 18
Medical/lateral tilt
Inferior/superior tilt
Medial/lateral glide
Internally/externally rotated
TEST: Biodex Gait Trainer evaluation
Gait symmetry
A-angle
Q-Angle
Foot biomechanics
*NOTE: The treatment of patellofemoral pain (chondromalacia patella or patellofemoral syndrome) has been shown to
be more successful when foot orthoses are used in conjunction with other treatment modalities.3
TEST: Bilateral Isometric knee extension/flexion evaluation
Device: Biodex Multi-Joint System
Pad Placement: Normal
Setup: 60º of knee flexion
Mode: Isometric
Sets and Duration: 1 x 10 reps x 5 seconds each
Recommendations: Must be performed pain free and without crepitis
TEST: Biodex Open Kinetic Chain (OKC) Proprioception
Passive and Active Joint position sense
Pattern: Knee extension/flexion
Mode: Passive and Isokinetic
Sets and Reps: 1 x 5 each target angle
Target angles: 90º/60º/30º
Recommendations: There should be no incidence of pain or inhibition with movement
2-4 PHASE I: REDUCTION OF ACUTE SYMPTOMS

CLINICAL TREATMENT OPTIONS:
• Rehabilitation process education:
Introduce patient to clinic/staff
Describe rehabilitation process
Define goals to the patient
• Patellofemoral bracing or strapping 15
NOTE: It has been noted in the literature that by strapping the knee, you will increase not only the force output both
concentrically and eccentrically, but decrease the perceived amount of pain.
This was not noted for the bracing. Bracing increased eccentric force and decreased pain, but no
concentric changes were noted. 6
• Avoid Weight-bearing ADL's which compromise articular surface 7
• Correct lower extremity biomechanical with ambulation training
• Reduce joint effusion/manage pain:
P.R.I.C.E.
• Patella mobilizations for hypomobility PRN:
Medial, superior and inferior glides
Stress medially to stretch lateral retinaculum
• Cardiovascular training:
Device: Biodex BioStep® Semi-Recumbent Elliptical
Mode: Isokinetic
Duration: 10 min
Speed: 120 deg/sec
Intensity: 70% Maximum Heart Rate (MHR)
Device: Biodex Upper Body Cycle
Mode: Isokinetic
Duration: 5-7 min
Speed: 90 deg/sec
Intensity: 70% Maximum Heart Rate (MHR)
• Isometric strengthening:
Mode: Isometric
Pattern: Knee Ext/Flex
Setup: 90º/60º/30º/0º
Sets and Reps: 2 x 10 x 10 sec hold each
Recommendation: Use electrical stimulation to increase motor unit recruitment.6

CLINICAL TREATMENT OPTIONS (cont):
• Quadriceps re-education for disuse atrophy:
Device: "Quad sets" with Electro Neuromuscular Stimulation (ENS) and biofeedback. 27
Enhance VMO:VL ratio towards uninvolved level (normal is 1:1)
Sets and Reps: 3 x 10 –12
Duration: 10 sec hold
Repeat: 3-4 times daily
Pattern: Knee FLEX/EXT
ROM: 45º of flexion to full extension
Mode: Passive
Speed: 10 deg/sec
Pause: 10 sec in extension
Duration: 10 min.
Recommendations: Set torque limits to half of limb weight. Instruct patient to maintain constant movement of 10 deg/sec.
Patient should perform a "Quad set" during pause. Use electrical stimulation to increase motor unit recruitment. 6
• Weight-bearing Proprioception/Stability:
Device: Biodex Balance System
Stance: Bilateral (Two feet)
Eyes: Open
Setup: Dynamic Balance Training
Stability level: 8 (most stable) progress to 6 (less stable)
Duration: 3 bouts of 30 sec (progress to 5 bouts as tolerated)
Recommendations: Utilize Biodex Unweighing System if patient is able to partially weigh bear (PWB) during exercise.
Unweigh patient up to 60% of body weight. Patient should be instructed to hold handrails during initial training.
• Weight-bearing Proprioception:
Passive and Active Joint position sense
• Flexibility program: 23
Hamstrings seated
IT band Supine over the table
Quadriceps
Gastrocnemius/Soleus
Hold each stretch for 20 sec repeat 5-6 times
NOTE: May have to hold some quad stretching if the patient has medial/adductor patella facet syndrome.

SUPERVISED PROGRAM:
(frequencies prescribed on individual basis)
• Reduce swelling and manage pain:
P.R.I.C.E.
• Patellofemoral bracing/strapping
• Muscle re-education for disuse atrophy
Biofeedback Electrical Stimulation (EMS) as prescribed
• Cardiovascular Training:
Mode: Isokinetic
Duration: 12 min
Speed: 110 deg/sec
Intensity: 75% MHR
Mode: Isokinetic
Duration: 7-10 min
Speed: 80 deg/sec
Intensity: 75% MHR
Device: Biodex Rehabilitation Treadmill
Speed: 2.0 mph
Incline: O%
Position: Straight ahead walking
Time: 5-7 min
Intensity: 65-75% MHR
• Flexibility:
Hamstrings seated
IT band
Supine over table rectus femoris/quads
• Muscle Re-education and strengthening:
Leg Raises: FLEX/EXT/ADD
Hold from initiating abduction leg raises due to possible tight lateral structures and
weak medial musculature. 9
Seated Isometrics
90, 75, and 60º of knee flexion 1
Sets and Reps: 3 x 10 each angle

HOME PROGRAM
• Control pain and edema:
P.R.I.C.E.
Modalities/Medications as prescribed
• Range of Motion (ROM) exercises:
PROM knee FLEX/EXT with contralateral limb
Sets and Reps: 3 x 10
Repeat: 4x/day
• Strengthening
"Quad sets" at 0º and 90º of knee flexion
Sets and Reps: 1x 10
Hold contraction: 10 seconds
Repeat: 2x/day
Mini squats:
Repeat: 2x/day
Recommendations: Stand between two chairs, feet shoulder width apart, keeping the patella
over the second metatarsal. Squat down to 30º knee flexion and slowly return to standing.
• Flexibility training: (static stretch only)
Quadriceps
Hamstrings
IT band
Sets and duration: 5-6 x 20 seconds
Repeat: 2x/day
REPORTS:
• Analog pain scale
• Range of Motion
• Cardiovascular fitness level
• Biodex Bilateral OKC proprioception test
• Biodex isometric bilateral comparison QUAD/HAM @ 60 deg/sec
• Biodex Gait Trainer evaluation
• Biodex Stability Index

PHASE II
GOALS:
• Decrease pain and inflammation
• Increase flexibility with pain-free PROM and AROM
• Decrease symptoms with ADL’s
• Restore full AROM
• Restore normal patellar mobility
• Increase cardiovascular conditioning
• Increase VMO:VL ratio to > 75%
• OKC Proprioception < 25% deficit
• Isometric QUAD/HAM strength < 10% deficit
• Isokinetic QUAD/HAM strength < 30% deficit
• Stability Index: Bilateral stance < 25% deficit from normative goal
range of motion & initial strengthening

• Pain scale:
• Edema:
Patella ballottement test; mid-patella circumferential measurement
• Goniometry: 12
Knee flexion/extension (0-135º knee flexion) active and passive
• Biofeedback evaluation: Vastus medialis:lateralis (VMO:VL) ratio 16
TEST: Bilateral Isometric knee FLEX/EXT evaluation
Setup: 30º/60º/90º of knee flexion
Mode: Isometric
TEST: Bilateral Isokinetic knee FLEX/EXT evaluation
Pad Placement: normal
Setup: pain free ROM
Mode: Isokinetic
Sets and Reps: 1 x 5 @ 180 deg/sec
1 x 15 @ 300 deg/sec
Recommendations: ROM should be limited to avoid crepitis and allow for safe speed training.
TEST: Bilateral OKC Proprioception test
Passive and Active position sense
TEST: Stability Index 24
Stability level: Level 6
Trials and Duration: 3 x 30 seconds
Eyes: open
Recommendation: Prepare to support patient during test. Instruct patient to use handrails as needed.
2-10 PHASE II: RANGE OF MOTION AND INITIAL STRENGTHENING

• Reduce joint effusion/manage pain:
P.R.I.C.E.
• Patella mobilizations:
Medial, superior and inferior glides
Mode: Isokinetic
Duration: 15 min
Speed: 120 deg/sec
Intensity: 75% MHR
Mode: Isokinetic
Duration: 10 min
Speed: 90 deg/sec
Intensity: 75% MHR
• Retroambulation: 8
Speed: 2.0 mph
Incline: 12%
Duration: 10 min
• Postural Control Exercises
• Strengthening:
Mode: Isometric
Pattern: Knee Ext/Flex
Setup: 90º/60º/30º/0º
Sets and Reps: 2 x 10 x 10 sec hold each
Recommendation: With poor "quad set", use electrical stimulation to increase motor unit recruitment.
Pattern: knee FLEX/EXT
Mode: Isokinetic
Setup: Pain-free ROM and limit crepitis
Speeds: 180 and 300 deg/sec in both directions27
Sets and Reps: 3 x 15 (progress to 20-30)

• Strengthening (Cont):
Device: Biodex Multi-Joint System Closed Chain Attachment
Pattern: Leg press
Mode: Isokinetic
Setup: 0-45º
Speeds: 60 deg/sec
3 plane SLR
Sets and Reps: 3 x 15-20 (progress to 30)
Weight-bearing exercises:
4" One-legged step-ups
Wall squats
Leg press
Mini-squats with physioball between knees to increase EMG output from the VMO*
Sets and Reps: 2 x 10 each (progress to 3 x 15)
ROM: 0º-45º
*NOTE: The VMO takes its origin from the adductor longus and magnus.12
Weight-bearing exercises should be
performed in a pain-free ROM and without crepitus. At the same time, the patella should at not go anterior to the toes.
• Weight-bearing Proprioception:
Stance: Bilateral (Both feet)
Level: Level 6 progressing to level 4
Sets and Duration: 3 x 30 seconds (progress to 3 min continual)
Eyes: open (progress to closed)
Training method: Trace circles on screen (A-D), color in circles (A-B)
Recommendations: Have patient progress to using no hands
• Non-weight-bearing Proprioception:
Pattern: Knee EXT/FLEX
Hold: 10 seconds

SUPERVISED PROGRAM:
(Frequencies prescribed on individual basis)
P.R.I.C.E.
• Muscle re-education for disuse atrophy
Biofeedback Electrical Stimulation (EMS)
Mode: Isokinetic
Seat height: normal
Pedal length: normal
Duration: 15 min
Speed: 120 deg/sec
Mode: Isokinetic
Duration: 7-10 min
Speed: 90 deg/sec
Direction: Retroambulation
Speed: 2.0 mph
Incline: 12%
Time: 10 min
• Muscle Re-education and strengthening:
Leg raises with ankle weights
Sets and Reps: 3 x 15 each direction
Hold from initiating abduction
Seated Isometrics
90º knee flexion up to greatest extended position without pain or crepitus
Sets and Reps: 3 x 15 each angle
Wall squats with ball between knees
Sets and Duration: 2 x 20 seconds (progress to 5 sets)
Calf raises
Sets and Reps: 3 x 10 (progress to 20)
Instruct patient to perform raise with both feet. Initial raises should be done from flat surface and progress to 4" step.
(Frequencies prescribed on individual basis)
• Flexibility:
Hamstrings seated
IT band
Supine over table rectus femoris/quads

HOME PROGRAM:
P.R.I.C.E.
• Electro Neuromuscular Stimulation (ENS) as directed
• Range of Motion (ROM) exercises:
PROM knee EXT/FLEX with contralateral limb
Repeat: 4x/day
• Strengthening
"Quad sets" at 0º and 90º of knee flexion
Sets and Reps: 1x 10
Hold contraction: 10 seconds
Repeat: 2x/day
Mini squats
Repeat: 2x/day
3-way SLR
Repeat: 2x/day
Resistance: begin with none and progress to 3-5 pounds
Recommendations: Continue to hold abductor leg raises.
Quadriceps
Hamstrings
IT band
Gastrocnemius/soleus
Repeat: 2x/day
• Cardiovascular training
30 min at 65-80% MHR 3-4x /week
REPORTS:
• Range of Motion
• Biodex isometric bilateral comparison QUAD/HAM @ 60º
• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec (as tolerated)
• Biodex Gait Trainer Exercise Summary

PHASE III
GOALS:
• Increase flexibility with pain-free PROM and AROM
• No pain with ADL’s
• Restore full AROM
• Restore normal VMO:VL firing sequence
• Increase VMO:VL ratio to 100%
• Isometric QUAD/HAM strength = bilaterally or WNL
initial weight-bearing &
intermediate strengthening

• Evaluate muscle hypertrophy
• Pain scale:
• Edema:
• Goniometry:
Knee FLEX/EXT (0-135º knee flexion) active and passive
• Biofeedback evaluation: VMO:VL ratio
NOTE: Current research trends point to VMO/VL ratios in time-based evaluations. However, this was noted
through fine wire electrode EMG. Clinically the most applicable means is through surface EMG VMO/VL ratio.
TEST: Bilateral Isometric knee EXT/FLEX evaluation
Setup: 30º/60º/90º of knee flexion
Mode: Isometric
Setup: pain free ROM
Mode: Isokinetic
Sets and Reps: 1 x 5 @ 180 deg/sec, 1 x 15 @ 300 deg/sec
TEST: Stability Index
Eyes: open
Pattern: Knee EXT/FLEX
Target angles: 90º/60º/30º/15º
2-16 PHASE III: INITIAL WEIGHT-BEARING & INTERMEDIATE STRENGTHENING

• Reduce pain and edema
P.R.I.C.E.
Electro Neuromuscular Stimulation (ENS)
• Continue with patellofemoral bracing/strapping
• Strengthening:
Pattern: knee EXT/FLEX concentric/concentric
Mode: Isokinetic
Pad placement: normal
Setup: Pain-free ROM and no crepitus
Speeds: 180-500 deg/sec in both directions
Sets and Reps: 5 x 10 (progress to 10 x 10)
Recommendations: Have patient perform velocity spectrum
Pattern: knee EXT/FLEX concentric/eccentric
Mode: Passive
Setup: Full extension to 60º of flexion
Speeds: 60 deg/sec
Sets and Reps: 2 x 10 (progress to 3 x 15)
Resistance: Initial torque levels should be based on concentric and isometric test results.
Recommendations: Instruct patient to contract quadriceps into extension and to resist movement into flexion.
There should be no pain or crepitus with this movement.
Weight-bearing strengthening exercises:
Mini-squats with physioball between knees to increase EMG output from the VMO*.
Sets and Reps: 3x15 each
ROM: 0º-90º (secondary to joint reaction forces)
8" One-legged step-ups and step-downs
Leg presses
Single leg calf raises
Sets and Reps: 3 x 10 each
Wall squats with physioball behind back
Sets and Duration: 2 x 30 seconds
Isotonic strengthening:
Device: Recumbent Squat
Foot position: tibia parallel to the ground
*NOTE: This exercise should be performed in a pain-free ROM and with no crepitus. Also, the patella should at no time
go anterior to the toes.

CLINICAL TREATMENT OPTIONS (CONT):
Isotonic strengthening (Cont):
PNF patterns on Cable Column to increase resistance
• Weight-bearing proprioception:
Stance: Unilateral
Level: Level 4 progressing to level 2
Eyes: Closed
• Non-weight-bearing proprioception:
Hold: 10 seconds
Target angles: 90º/75º/60º/45º/30º/15º/0º
Recommendations: There should be no incidence of pain or inhibition with movement.
Mode: Isokinetic
Duration: 15 min
Speed: 100 deg/sec
Mode: Isokinetic
Duration: 10 min
Speed: 80 deg/sec
Device:Biodex Rehabilitation Treadmill
Direction: Forward Jogging on
Speed: 4.5 mph
Incline: 0%
Duration: 5-10 min
Aquatic Therapy
15-20 min
• Flexibility training:
Quadriceps
Hamstrings
IT band

SUPERVISED PROGRAM:
(Frequencies prescribed on an individual basis)
P.R.I.C.E.
Mode: Isokinetic
Duration: 15 min
Speed: 100 deg/sec
Mode: Isokinetic
Duration: 10 min
Speed: 80 deg/sec
Direction: Retroambulation
Speed: 2.5 mph
Incline: 12%
Time: 15 min
Direction: Forward jogging
Speed: 3-5 mph
Incline: 0%
Duration: 5-15 min
• Strength training:
Leg raises
Sets and Reps: 3 x 15 each direction
Knee extension (concentric/eccentric quadriceps)
Sets and Reps: 3 x 12-15
Recommendations: Perform the exercise in pain free ROM
Wall squats with ball between knees
Sets and Duration: 2 x 20 seconds (progress to 5 sets)
Single-leg calf raises
Sets and Reps: 3 x 10 (progress to 20)
(Frequencies prescribed on an individual basis)

SUPERVISED PROGRAM (cont):
• Strength training (Cont):
Weight: begin with 3-4 plates and progress as tolerated
NOTE: This exercise should be performed in a pain-free ROM and with no crepitus. It is imperative that the patella does
not travel medially and /or laterally during the motion. Also, the patella should at no time go anterior to the toes.
Quadriceps
Hamstrings
IT band

HOME PROGRAM:
P.R.I.C.E.
• Strengthening
Active knee extension
Resistance: Start with a 5 pound cuff weight and progress to 10 pounds
Repeat: 2x/day
Recommendations: Pain-free ROM and with no crepitis
Mini squats
Sets and Reps: 3 x 15 -20
Repeat: 2x/day
Recommendations: Stand between two chairs, feet shoulder width apart, keeping the patella over the second
metatarsal. Squat down to 45º knee flexion and slowly return to standing.
3-way SLR
Repeat: 2x/day
Resistance: 3-5 pounds
Recommendations: Continue to hold abductor leg raises if lateral structures remain inflexible or VMO is deficient.
Wall Sit
Sets and Duration: 2 x 30 sec
Repeat: 3x/day
Position: 45º
Heel raises
Position: Both feet (progress to single)
Repeat: 2x/day
Quadriceps
Hamstrings
IT band
Repeat: 2x/day
30 min at 65-80% MHR 3-4x/week

REPORTS:
• Range of Motion
• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec (as tolerated)
• Biodex Gait Trainer Exercise Summaries

PHASE IV
GOALS:
• Maintain flexibility with pain-free PROM and AROM
• Maintain pain-free with all activities
• Maintain full AROM
• Maintain normal patellar mobility
• Maintain normal VMO:VL firing sequence
• Maintain VMO:VL ratio at 1:1
• Isokinetic QUAD concentric/eccentric strength < 85% bilaterally
• Single leg hop, 6 meter timed hop and crossover hop < 15% deficit lower extremity 19
return to activity

• Evaluate muscle hypertrophy
• Pain scale:
• Edema:
• Goniometry:
Knee FLEX/EXT (0º-135º knee flexion) active and passive
• Biofeedback evaluation: Vastus medialis:lateralis (VMO:VL) ratio 16
Setup: Full pain-free ROM
Mode: Isokinetic
Sets and Reps: 1 x 5 @ 180 deg/sec
1 x 15 @ 300 deg/sec
TEST: Stability Index
Report: Stability Index
Eyes: open
Target angles: 90º/60º/30º/15º
Recommendations: There should be no incidence of pain or inhibition with movement.
TEST: Hop tests
Single leg hop, 6 meter hop and crossover hop tests
Trials: Average of three
Take off: On the involved extremity
Landing: On the involved extremity
2-24 PHASE IV: RETURN TO ACTIVITY

P.R.I.C.E.
• Continue with patellofemoral bracing/strapping PRN
• Flexibility training:
Quadriceps
Hamstrings
IT band
Mode: Isokinetic
Duration: 20 min
Speed: 100 deg/sec
Mode: Isokinetic
Duration: 20 min
Speed: 80 deg/sec
Direction: forward jogging/running
Speed: 5.0 mph as tolerated
Incline: 0% as tolerated
Duration: 10-15 min
Device: Fitter
Duration: 10-12 min
• Proprioceptive Neuromuscular Facilitation (PNF) patterns for the Lower Extremity:
Device: Cable Column
Recommendations: Perform hip adduction only if VMO:VL ratio is 1:1 and has no complaints of increased signs or symptoms.
NOTE: Should perform exercises on involved and uninvolved side
• Weight-bearing Proprioception
Stance: Unilateral
Level: Level 2 progressing to Level 1
Eyes: Closed

• Weight-bearing/Partial weight-bearing isotonic strengthening:
Device: Functional Squat System or Isotonic Squat
Weight: use weight as tolerated
NOTE: This exercise should be performed in a pain/crepitus free ROM. It is imperative that the
clinician ensures that the patient’s patella should at no time go anterior to the toes.
Device: Mini-squats with physioball
Pattern: 60º/75º/90º of knee flexion
Sets and Reps: 3 x 12 each
Device: Cable Column
Pattern: Single leg mini squats
Pattern: Plyometrics
Foot position: Begin in center of platform (progress to various positions throughout)
Weight: 3 plates to begin, progress as tolerated
NOTE: This is an alternative to standing plyometrics. The clinician may want to utilize the squat system for increased
control of patient movement. Assure proper foot position as well as the foot slipping off the edge of the platform.
Lateral step-down
Recommendations: Perform step-down from 4" height and progress to 8"
Wall Seats with ball between knees
Sets and Reps: 3 x 12 with 10 sec hold
Recommendations: Instruct patient to push heels into ground and to pull toes up while performing this exercise.
Heel raises (Seated and Standing)

• Isokinetic Strengthening:
Pattern: Knee flexion/extension Concentric/Concentric training
Setup: crepitus/pain free ROM
Mode: Isokinetic
Speeds: 180-450 deg/sec in both directions
Recommendations: Progress to 30 seconds at each speed instead of reps.
Pattern: Knee extension Concentric/Eccentric training
Setup: 60- 0º of knee flexion
Mode: Passive
Speeds: 60 deg/sec
Recommendations: Instruct patient to actively contract quadriceps into extension and to resist movement into flexion.
Once patient has understanding of eccentric muscle contractions, change mode to Reactive Eccentric and set torque
limits based on test values.
• Functional Program:
Plyometric program 11
Return to sport progression
SUPERVISED PROGRAM:
(Frequencies prescribes on an individual basis)
• Patellofemoral brace/strap to facilitate pain free exercise
• Strengthening program:
Isotonic Progressive Resistance Exercises (PREs)
Hip adduction, abduction, flexion and extension
Resistance: 10-12 Ib
Recommendations: Perform on both involved and uninvolved lower extremities
Knee extension (concentric/eccentric quadriceps)
Recommendations: Should have full pain free ROM
Knee flexion (concentric/eccentric hamstrings)
Recommendations: Should have full pain free ROM
Weight: as tolerated
NOTE: This exercise should be performed pain-free and with no crepitis. At the same time, the patella should at no time
go anterior to the toes.

SUPERVISED PROGRAM (cont):
Mode: Isokinetic
Seat height: normal
Pedal length: normal
Duration: 20 min
Speed: 100 deg/sec
Intensity: 80% MHR
Mode: Isokinetic
Duration: 20 min
Speed: 80 deg/sec
Intensity: 80% MHR
Direction: Forward
Speed: 4-8 mph
Incline: as needed
Duration: Vary depending on sport/activity
Note: Perform exercises as per athletic competition as well as different patterns (i.e., cross-over steps, side-steps)
Slide Board
Duration: 10-12 min
Fitter
Duration: 8-12 min
Aquatic therapy
Sport/activity specific exercises and conditioning techniques

HOME PROGRAM:
• Reduce pain and edema:
P.R.I.C.E.
• Strengthening:
Active knee FLEX/EXT
Resistance: Start with a 10 pound cuff weight and progress to 15 pounds
Recommendations: Pain-free ROM and with no crepitis
Mini squats
Sets and Reps: 3 x 15 -20
Repeat: 2x/day
3-way SLR
Repeat: 2x/day
Resistance: 3-5 pounds
Recommendations: Continue to hold abductor leg raises if lateral structures remain inflexible or VMO is deficient.
Wall Sit
Sets and Duration: 2 x 45 sec
Repeat: 2x/day
Position: 45º
Heel raises
Position: Both feet (progress to single)
Repeat: 2x/day
Quadriceps
Hamstrings
IT band
Repeat: 2x/day
30 min at 65-80% MHR 3-4x /week
Sport specific drills and conditioning techniques
• Functional progression: 5
15 heel raises
Walking at fast pace
Jumping on both legs
Hopping on the involved leg
Jog straight and curves
Run straight at 1/2 speed, 3/4 speed, and then full speed
Run large figure - 8's (20 yards) at 1/2, 3/4, and full speed
Run small figure - 8's (10 yards) at 1/2, 3/4, and full speed
Cross-over run in both directions
Run on uneven terrain
Run up, down, and sideways on hills
Cutting (wearing athletic shoes on asphalt) at 1/2, 3/4, and full speed
NOTE: Patients can progress through each step only if asymptomatic

REPORTS:
• Range of Motion
• Biodex isokinetic bilateral comparison QUAD/HAM @ 180 and 300 deg/sec
• Biodex isokinetic bilateral comparison QUAD/HAM Concentric/Eccentric comparison
• Biodex Gait Trainer evaluation
• Biodex Bilateral and Unilateral Stability Index

BIODEX BALANCE SYSTEM
NORMATIVE VALUES:
Age (yrs) Stability Index Standard Deviation (+/–)
17-35 1.54 .72
36-53 2.13 .90
54-71 2.57 .78
72-89 2.70 .80
Females are more stable than males:
All ages Stability Index Standard Deviation
Females 1.94 .80
Males 2.70 .08
Values were collected by J.A. Finn, et al, Stability Performance Assessment among Subjects of Disparate Balancing Abilities.
Southern Connecticut State University.
stability index

EVIDENCE-BASED CLINICAL
PROTOCOL FOR
REHABILITATION OF
PATELLOFEMORAL DYSFUNCTION
1. Brownstein. VMO EMG activity was highest between 90°-60°, lowest between 0°-30° (hip adduction therapy may help
enhance the VMO of attachment to adductor magus. JOSPT, 1985.
2. Conway A, Malone TR, and Conway P. Patella Alignment/Tracking Alteration: Effect on Force Output and perceived pain.
Isokinetics and Exercise Science: (2) No. 1, 1992.
3. D'Amico JC, Rubin M. The Influence of Foot Orthoses on the Quadriceps Angle, J.A.P.A.: 76(6) 337-340, 1986.
4. DeAndrade JR., et al. Joint distention and reflex muscle inhibition in the knee. JBKJS (AM): 47:313-322, 1965.
5. DeMaio M, Mangine RE, Noyes FR, and Barber SD. Advanced Muscle Training After ACL Reconstruction: Weeks 6 to 52.
Sport Medicine Rehabilitation Series: 757-767. 1993.
6. Draper V, Ballard L. Electrical stimulation versus electromyographic biofeedback in the recovery of quadriceps femoris muscle
function following anterior cruciate ligament surgery. Physical Therapy, Vol. 71 p. 455-461. 1991.
7. Eifert-Mangine M, Mangine R, Vasquez A. Overuse Syndrome of the Patellafemoral Joint. Orthopedics, 1991.
8. Flynn TT, Soutas-Little RW. Mechanical Power and Muscle Action During Forward and Backward Running.
JOSPT: (17)2: 108-112. 1993.
9. Hanten WP, Schulties SS. Exercise effect on EMG activity of the VMO and VL muscle. Physical Therapy: 70:561-565
10. Hodges PW, Richardson CA. The influence of isometric hip adduction on quadriceps femoris activity. Journal of Rehabilitation
Medicine: 25:57-62, 1995.
11. Hollonshead WH, Jenkins DB. Functional anatomy of the limbs and back. Philadelphia, Saunders. 1981.
12. Hoppenfeld S. Physical Examination of the Spine and Extremities. Appleton-Century--Crofts. p.187, 1976.
13. Insall JN, Salvati. Patella Position in the Normal Knee Joint. Radiology 101:101-104, 1971.
14. Kiernan, H. Physical Exam and Differential Diagnosis p.31.
15. Kip. McConnell tape increased VMO/VL ratio at 90° of knee flexion no effect at 15°-30° of flexion. Medicine Science Sport and
Exercise. 1992.
16. Lephart SM, Kocher MS, Fu FH, Borsa PA, and Horner CD. Proprioception Following Anterior Cruciate Ligament
Reconstruction. Journal of Sport Rehabilitation: Vol 1: 188-196. 1992.
17. Mangine R. Physical Therapy of the Knee. Clinics in Physical Therapy. Vol. 19, Churchill Livingstone, 1988.
18. McConnell J. The Management of Chondromalacia Patella: A Long Term Solution. The Australian Journal of Physiotherapy,
Vol 31(4):214-223, 1986.
19. Noyes FR, Barber SD, Moorar LA. Abnormal lower limb symmetry determined by function hop test after anterior cruciate
ligament rupture. American Journal of Sport Medicine:19(5):513-518, 1991.
20. Puniello MS. Iliotibial band tightness and medial patella glide in patients with patellofemoral dysfunction.
JOSPT: 17(3): 144-148, 1993.
21. Reynolds. EMG data in normal VMO/VL ratio 1:1. EMG data in patellofemoral patients VMO/VL ratio greater than 1:1.
American Journal of Physical Medicine.
22. Sczepanski T, Gross M, Duncan P, Chandler J. Effect of Contraction Type, Angular Velocity, and Arc of Motion on VMO:VL
EMG ratio. JOSPT. (14) 6, 1991.
23. Smith CA. The Warm-Up Procedure: To Stretch or Not to Stretch. A Brief Review. JOSPT (19)1-12, 1994.
references

24. Voight ML, Blackburn TA, Soffer SS, Bowman J. Single Leg Stance: Development of Reliable Testing Procedures. Submitted as
abstract: 1995 Combined Sections.
25. Voight, Ml, Weider D. Comparative reflex response times of VMO and VL in normal subjects with exterior mechanism dysfunc-
tion. American Journal of Sports Medicine, 19: 131-137, 1991.
26. Wilk KE, Andrews JR. The Effect of Pad Placement and Angular Velocity on Tibial Displacement During Isokinetic Exercise.
JOSPT: (17)1: 24-30. 1993.
27. Wise HH., et al. EMG biofeedback as treatment for patellofemoral pain syndrome. JOSPT 6:95-103, 1984.
2-34 REFERENCES

EVIDENCE BASED CLINICAL PROTOCOL FOR
THE MANAGEMENT OF:
patellofemoral dysfunction
post Injury: phase I:
Reduction of Acute Symptoms
phase II:
Range of Motion and Initial Strengthening
• Mentally prepare patient for rehabilitation
• Education of Pt to understand the problems of
PF dysfunction
• Identify specific needs of patient and
potential problems
• Decrease pain and edema
• Maintain ankle ROM and strength
• Full knee PROM
• Increase VMO:VL strength ratio to 50%
• OKC Proprioception < 40% deficit of uninvolved side
• Isometric strength QUAD/HAM < 30% deficit
• Normalize gait deviations and correct
biomechanical faults
• Identify contributory factors
• Stability Index
• Rehabilitation process education
• Patellar bracing or strapping
• Patellar mobilization
• Correct biomechanical dysfunction/
ambulation training
• Flexibility training
• Muscle re-education of QUADS
• Strengthening: Multi-angle isometrics
• WB Proprioception: Biodex Balance System
bilateral stance
• Cardiovascular training: Biodex UBC, SRC
• General patient history and observation
• Pain scale: location, quality and duration
• Degree and type of edema
• Range of motion: active and passive
• Goniometry (0-135 degrees)
• Patella assessment (radiographs, palpation, physical)
• Neurological assessment: myotomes, dermatomes
and reflexes
• TEST: Biodex bilateral isometric test 3 position
QUAD/HAM (30, 60,90) OR
• TEST: Biodex bilateral isokinetic test
QUAD/HAM @ 300 deg/sec
• TEST: Biodex OKC proprioception test
• TEST: Biodex Balance System bilateral stance
• TEST: Biodex Gait Trainer assessment
• Control edema and manage pain
• Muscle re-education
-EMS, isometrics
• Cardiovascular training: Biodex UBC or LBC
• Control pain and edema
• ROM exercises
• EMS
• Non-WB strengthening exercises
• Range of motion
• Pain scale
• Biodex bilateral OKC proprioception test
• Biodex isometric OR isokinetic bilateral comparison
• Biodex Balance System bilateral stance test
• Increase flexibility with pain free PROM and AROM
• Increase VMO: VL ratio to > 75%
• Isometric QUAD/HAM strength < 10% deficit
• Stability index: Bilateral stance < 25% deficit
• Reduce edema / inflammation
• Reduce spasm / pain
• Patellar mobilizations
• ROM: AAROM QUAD/HAM
• Postural control
• Strengthening exercises:
- Biodex multi-angle isometric QUAD/HAM
- Biodex isokinetic QUAD/HAM
@180/300 deg/sec
• Non-WB Proprioception: Biodex MJS
• WB Proprioception:
Biodex Balance System bilateral stance
• WB and partial WB Exercises:
- Wall squats, step-ups
- Biodex CC Attachment
• Cardiovascular training: Biodex UBC,
LBC or Treadmill
• Verify home program compliance
• Degree and character of edema
• ROM testing: AROM and PROM (0-135 degrees)
• TEST: Biodex bilateral isometric
QUAD/HAM @ 30, 60, 90 deg
• TEST: Biodex bilateral isokinetic
QUAD/HAM @ 180/300 deg/sec
• TEST: Biodex bilateral proprioception QUAD/HAM
• TEST: Biodex Balance System bilateral stance
• Muscle re-education
• Strengthening: Hip, knee, lower leg & ankle*
• Flexibility: Hip, knee, lower leg and ankle
• Cardiovascular training: Biodex UBC, LBC or Treadmill
*NOTE: No hip adduction with knee exercises
• Non-WB strengthening: Hip, knee, lower leg & ankle*
• Cardiovascular training: 20-30 min. 3-4 x/wk
• Range of motion
• Pain scale
• Biodex isometric AND isokinetic bilateral comparison
• Biodex Balance System bilateral stance test
• Biodex Gait Trainer Evaluation
goals:
clinical
treatment
options:
clinical
evaluations:
supervised
program:
home
program:
reports:

EVIDENCE BASED CLINICAL PROTOCOL FOR
THE MANAGEMENT OF:
patellofemoral dysfunction
phase III:
Initial Weight-bearing and
Intermediate Strengthening
phase IV:
Return to Activity
• Pain-free with activity
• No effusion and full ROM
• Maintain normal patellar mobility
• Activity specific tests WNL
• Isokinetic strength QUAD/HAM < 10% deficit
• Isokinetic strength con/ecc (quads only)
< 85% deficit
• Functional hop test < 15% deficit
• Stability index: unilateral stance < 10% deficit
• Maintain VMO:VL ratio
• Maintain VMO:VL firing sequence
• ROM exercises
• Strengthening:
- Biodex isokinetic QUAD/HAM @
(60, 180, 300)
- Isotonics WB and Non-WB
- Isotonics for lower extremity (no hip AD)
- Biodex isokinetic con/ecc
QUAD @ 60/180 deg/sec
• Non-WB proprioception: Biodex M-JS
• WB proprioception: Biodex Balance System
unilateral stance
• Flexibility Training
• Cardiovascular Training (UBC, TM)
• Functional Program
• ROM: active and passive
• Muscle hypertrophy
• Pain scale
• Edema
• Goniometry (0-135 degrees)
• TEST: Functional hop test
• TEST: Biodex bilateral isokinetic
QUAD/HAM (60, 180, 300)
• TEST: Biodex OKC proprioception
(passive, isokinetic)
• TEST: Biodex Balance System unilateral stance
• Functional activity evaluation
• Strengthening: Hip, knee, lower leg and ankle
• Cardiovascular training: Biodex UBC,
LBC or Treadmill
• Initiate interval sports program
• WB strengthening: Hip, knee, lower leg and ankle
• Initiate interval sports program
• Range of motion
• Biodex isokinetic bilateral comparison
(60, 180, 300 deg/sec)
• Biodex Balance System unilateral stance test
• Patellofemoral Outcome Report
• Full pain free ROM
• No effusion
• No complaints of palpable tenderness
• Restore normal VMO: VL ratio
• Increase flexibility
• Isokinetic strength < 15% deficit
• Isokinetic strength (con/ecc) < 15% deficit (quad only)
• Isometric strength = bilaterally or WNL
• Stability Index: Unilateral stance < 15% deficit
• Patellofemoral bracing/strapping - PRN
• ROM: active, passive and static
• Strengthening:
- Biodex isokinetic
QUAD/HAM (60, 180, 300)
- WB and Non-WB isotonics
- Biodex isokinetic con/ecc
QUAD @ 60 deg/sec
- Hip and ankle isotonics (no hip AD)
• OKC Proprioception training: Biodex M-JS
• CKC Proprioception: Biodex Balance System
unilateral stance
• Cardiovascular training: Biodex UBC, Treadmill
• Muscle hypertrophy
• ROM: full AROM and PROM (0-135 degrees)
• Biofeedback of VMO: VL ratio
• TEST: Biodex bilateral isokinetic test
QUAD/HAM (60, 180, 300)
• TEST: Biodex OKC proprioception active and passive
• TEST: Biodex Balance System unilateral stance
• TEST: Biodex Bilateral isometric multi angle
(30, 60, 90)
• Strengthening: Hip, knee, lower leg and ankle*
• Cardiovascular training: Biodex UBC, LBC or Treadmill
• Non-WB and WB strengthening: Hip, knee,
lower leg and ankle*
• Range of motion
• Pain scale
• Biodex isometric (60 degrees) AND isokinetic
bilateral comparison (180 and 300 deg/sec)
• Biodex Balance System unilateral stance test
goals:
clinical
treatment
options:
clinical
evaluations:
supervised
program:
home
program:
reports:

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