Ask Mike Reinold Podcast

Anterior Knee Pain After ACL Reconstruction


Anterior knee pain is one of the more common complications following ACL reconstruction surgery, especially if using a patellar tendon graft.

There are many reasons why this may occur, but by keeping this in mind from the beginning, we hope to minimize this from occurring.

Here’s what we do.

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#AskMikeReinold Episode 310: Anterior Knee Pain After ACL Reconstruction

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Jake Woodridge: We have Jeff from New Jersey. “I’ve been working the quad more after ACL reconstruction, incorporating things like full range, open kinetic chain knee extension, and earlier progressive loading. I’ve noticed that I’m seeing more people experience anterior knee pain, especially after a patellar tendon graft. How do you balance gaining strength and not flaring up a knee?”

Mike Reinold: Awesome. That’s a good question. I thought that was a real relevant question because I think a lot of people are probably doing this, right? Social media is pushing them a little bit to get more aggressive, and I bet for a lot of people, it’s probably the first time they’ve started to get a little bit more aggressive and you’re seeing a little bit of a bounce back.

So why don’t we start with that? And maybe Lenn, you can start off a little bit. How common is anterior knee pain after ACL reconstruction, especially patellar tendon graft? And do you think part of this trend and getting a little bit more aggressive is going to make that worse, or is there something we can do better? What do you think about this? I know you think about this a lot.

Lenny Macrina:
I think about it a lot. Actually, I talk about it a decent amount because when we always have students coming in, I let them kind of think through some of our ACLs and write programs for them. And it’s always interesting to see the variations in what they think should be going on. But I definitely think the social media trend of loading it, and now the open chain thing, is socially acceptable on social media.

Mike Reinold:
I like how you phrase that.

Lenny Macrina:
Full open kinetic chain, which I agree with. I’m not against that. It’s timing it. When you load the tissue early, especially a patellar tendon graft, you have a chance of irritating it. And remember, you have a patellar tendon and that’s like three centimeters wide and they take the middle third of it. So now that area has to scar down, and they took bone and bone plugs out from a patella and the tibia… There’s a lot that can get irritated very easily.

If we are trying to show the patient that we can load them, we want to load, you want to get the quads back and we keep loading, loading, loading the extensor mechanism, something’s got to give, whether it’s the fat pad, the patellar tendon itself, or even worse case, is the bones, the tibia or the patella, where you can get a fracture of the patella. Knock on wood, that’s never happened to me. But if you load it too early too quickly with single leg squats or squats, or even knee extensions, I would imagine it’s all going to irritate the area and it’s never going to heal correctly. And then you run the risk of that. So I don’t get a lot of…

Mike Reinold:
Lenn, you can go knee over toes. It’s a fact now, it’s science.

Lenny Macrina:
I’m going to create a social media account called “Knees Over Toes, Lenny.” I want to load it, trust me. I want to load my patients. It’s going to be a window where you’re getting the knee to calm down. And for me that’s about four to six weeks is that window.

What am I doing in that meantime? I’m getting swelling out, I’m getting patella mobility, I’m getting flexion range of motion, I’m getting extension range of motion. I’m slowly getting them to bear weight on their extremity. And I’m monitoring. I’m doing some soft tissue work at that area to get the tissue to move better, and I’m slowly adding stuff to see how they’re doing because I know that at 6, 7, 8 weeks, I can then be a little bit more aggressive and not worry about anterior knee pain.

My patients get anterior knee pain very rarely. And if it is, it’s very transient, very short-lived. So you got to slowly bring them along and have a systematic approach to what you’re doing. And your experiences will guide it. You’ll figure it out, hopefully. If not, you’re just going to keep getting the anterior knee pain in those patients, but you can’t load it too quickly. Give that four to six week window a chance for things to heal down and get that motion back and get the knee to calm down.

Mike Reinold:
It’s not that we’re against all this stuff. Yes, you need to do progressive loading stuff. Maybe you somehow tip the scales, right? Maybe you just did a little too much too soon or too often or whatever, maybe. Dave, what do you think?

Dave Tilley:
Yeah, I can just speak to a case that Chris and I were working with. This girl’s super competitive, ACL, and she came to us a little bit later, so it’s more like she came in the three-month phase and it was just a mixture of all of the factors, just kind of ramped up her volume just too fast, too quick.

I never want to speak ill of past therapists. She did a great job, but it seems like when you look at her program, it was just super quad heavy. It was like squatting, step-up, step-down, knee extension, and there wasn’t a lot of mixed programming going on along with doing stuff. So she was doing a really quad dominant program that was pretty much all quad and she got cleared to run just objectively on a protocol. So she started running, and of course she’s so competitive, she was going hard on her runs when she shouldn’t have been.

And then she started to go back to jumping and landing because she was cleared. So it wasn’t that anyone did anything particularly wrong, but it wasn’t a well-balanced program. And so she got really flared up. We had to back off a month because she also had some stuff that was a little irritable. I just think, unfortunately, it was just not looking holistically, “Can we get a hinge, a squat, a split pelvis, a step-up, a step-down, some hamstring, some quads, some calf, some balance.” Just trying to spread out her volume across all of it.

And then just some advice to people is that there’s a lot of ways you can load the quad. You can do it with squatting, sleds, split squats, step-ups. You can get a lot of different mechanisms and movements. She just didn’t tolerate squats. But she does great with step-ups, doesn’t tolerate step-downs. She does great with sleds. So we’re just trying to do stuff that she feels comfortable with and give her kind of mini wins.

Mike Reinold:
I like it. Dan, what do you think?

Dan Pope:
Yeah, a lot of good stuff here. I’ll try to be brief. I think sometimes with clinicians, we have a protocol. We’re at week four or week eight, we got to do lunges, we got to squat, this is the next step. And then sometimes patients get to it and it’s kind of provocative and irritating and it’s like, “Well, you’re at week eight, so we got to do it.” But I don’t think that always has to be the case.

I asked a lot of questions to the point where it’s kind of annoying to the patient. They’re like, “You’re the boss, you decide what’s going on.” And it’s like, “I want to know how this feels because if it’s not going well, we need to back off.” And I set that expectation with patients. It’s like, “All right, we’re ramping up and I think this is the right choice, but let me know how you feel tonight. Let me know how you feel tomorrow. Take notes on this, and if you’re not doing really well with it, we can back off or progress forward, depending.”

I think the last piece too, and I just mention this because I’ve done a lot of ACL kind of deep dive research lately, and blood flow restriction has kind of been studied a decent amount with ACL folks. And it’s interesting because you look at these studies and when they compare BFR training for the quad versus regular strength training, it seems like they’re pretty similar. So it’s not like the BFR is crushing and doing way better.

But I think the other thing to keep in mind is that you’re dealing with someone who has pain or some sort of irritation. And if you use blood flow restriction over heavier loading, you’re probably going to get a very similar change in hypertrophy and strength. It’s probably going to be much less aggravating, probably, because you can really reduce the loads.

I think trying to be smart about your progressions and be willing to change them if it doesn’t work well. And then if you are getting a ton of irritation, just do some BFR. I don’t think it’s going to set you back.

Mike Reinold:
That’s a good way of just peeling back.

Lenny Macrina:
There’s an analgesic effect of BFR too. I do a BFR two weeks after surgery and then I do that for the rest of their rehab, whether it’s during the beginning of their rehab when they’re doing all their leg raises, or if it’s at the end when they did a full program, squat, deadlifts, all that. And then I do BFR knee extensions at the end to really lock in the quads because we don’t have a knee extension machine. I think the BFR really has an assist in analgesic effect to that extension mechanism to that anterior knee.

Mike Reinold:
Yeah, I love that. I think the only thing I’d just caution against with BFR early after this is that we don’t have to jump right into an aggressive set rep scheme. And sometimes you get locked into 30, 30 30, or 30, 15, 15, 15. That might be aggressive too. You got to get there. But I love Dan’s concept on decreasing the load.

And then Jeff, I’m just going to take a step back and give you a little credit here and say that maybe this isn’t necessarily that you are overworking the quad. Maybe you’re doing everything and maybe you did increase your aggressiveness and quad strength in a beneficial way. I would say the primary reason that I’ve gotten anterior knee pain in ACLs in my career has almost always come to motion, not from overdoing their quad. So maybe you are emphasizing strength much more, and maybe they don’t have full knee extension or maybe their patellar mobility is down and that is causing some of the issues.

I would say to make sure their motion is still good. Maybe it’s not that you’re doing too much, but maybe their patellar mobility or their knee range of motion is down a little bit. I think those can lead to anterior knee pain, sometimes even more often in my experience.

I think putting that all together with what everybody said could really help though, just make sure we’re being intelligent with our application of load and not being aggressive just to be aggressive, but be intelligent and progressive.

This is a long progress. You don’t have to be as super aggressive the first two to four weeks. You’re going to be doing this with months with this person. The key is that you’re gradual and loading up over time, and that you’re getting them to that period where they can stimulate a little bit of their load. I think that would be fantastic.

So great question, Jeff. Really appreciate it. If you have a question like that, head to mikereinold.com, click on that podcast link and you can fill in the form to ask us a question. And please head to Apple Podcast, Spotify, to subscribe, rate, review. We would really appreciate it. We’ll keep doing these episodes as long as you keep asking some questions. We’ll see you on the next episode. Thanks so much.

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