When can a patient resume horseback riding after Medial Patellofemoral Ligament (MPFL) with Tibial Tubercle Osteotomy (TTO) surgery?

Return to Horseback Riding After MPFL with TTO Surgery

Patients can safely resume horseback riding approximately 6-8 months after MPFL with TTO surgery, provided they have met specific functional criteria including full range of motion, no pain or swelling, and >90% limb symmetry index in strength and functional testing.

Rehabilitation Timeline and Progression

Early Phase (0-6 weeks)

• Begin immediate knee mobilization within the first week to increase range of motion and prevent extension deficit 1
• Start isometric quadriceps exercises in the first week for muscle reactivation when they provoke no pain 1
• Implement weight bearing as tolerated with correct gait pattern, using crutches if needed 1
• Apply cryotherapy in the first postoperative week to manage pain and swelling 1

Intermediate Phase (6-12 weeks)

• Transition from isometric to concentric and eccentric exercises when the quadriceps is reactivated 1
• Begin closed kinetic chain (CKC) exercises from week 2 1
• Start open kinetic chain (OKC) exercises from week 4 in a restricted ROM of 90°-45° 1
• Gradually increase ROM in OKC exercises: 90°-30° in week 5,90°-20° in week 6,90°-10° in week 7, and full ROM in week 8 1
• Add neuromuscular training to strength training to optimize outcomes 1

Advanced Phase (3-6 months)

• Progress to sport-specific exercises and functional activities
• Implement eccentric training for greater strength gains and muscle hypertrophy 1
• Focus on quality of movement during all exercises 1
• Begin low-impact activities around 3-4 months if meeting progression criteria 1

Return to Horseback Riding Criteria

The decision to return to horseback riding should be based on objective criteria rather than time alone. Research shows significant variability in return-to-sport protocols after MPFL reconstruction with or without TTO, with many protocols failing to mention functional testing criteria 2.

Mandatory Criteria (all must be met):

1. No pain or swelling with activity
2. Full knee range of motion
3. Limb Symmetry Index (LSI) >90% for strength tests (particularly quadriceps and hamstrings) 1
4. LSI >90% for functional hop tests 1
5. Stable knee on clinical examination
6. Normalized patient-reported outcomes
7. Psychological readiness for return to activity

Special Considerations for Horseback Riding

• Horseback riding requires significant quadriceps and core strength for maintaining position
• Studies show that patients who undergo MPFL with TTO have greater strength deficits at 6 months and slower return to sport compared to isolated MPFL reconstruction 3
• Patients with combined procedures (MPFL+TTO) returned to sport at a mean of 8.1 ± 3.9 months 3

Progression to Full Riding

1. 6 months post-surgery: Begin with controlled mounting/dismounting practice and walking on a well-trained horse if meeting all criteria above
2. 7 months: Progress to posting trot on a level surface with proper form
3. 8 months: Resume full riding activities including cantering if all functional criteria are maintained

Common Pitfalls to Avoid

1. Premature return: Returning before adequate strength recovery increases risk of reinjury or compensation patterns
2. Neglecting quadriceps strengthening: Quadriceps strength deficits >20% have major impact on function and stability during riding 3
3. Focusing only on strength without neuromuscular control: Both components are essential for successful return to sport 1
4. Ignoring psychological readiness: Fear of reinjury can significantly impact performance and safety during riding 1

Monitoring After Return

Even after return to horseback riding, continue periodic strength assessments and maintenance exercises to ensure ongoing joint stability and function. Studies show that 85% of athletes can successfully return to sport after MPFL with TTO surgery with a low recurrence rate (3%) when following appropriate rehabilitation protocols 3.