On this episode of the #AskMikeReinold show we talk about some of the strategies and techniques we use to restore knee extension after surgery. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 182: Tips for Regaining Full Knee Extension After Surgery
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Mike Reinold: On this episode of The Ask Mike Reinold Show, we talk about some of the strategies we use to restore passive knee extension range of motion after a surgery.
Trey: Ellie from Florida asked, what are some methods you find most effective for gaining full knee extension in a post-surgical patient, with increased tone in the hamstrings?
Dave Tilley: I’ll answer this question. Jump on it.
Mike Reinold: Yes. All right. I like this, it’s a good question. What are some of the methods that we use to regain full knee extension after surgery? Now they, Ellie, specifically mentioned, with tone in the hamstring, which definitely is a thing and is definitely something that happens post-op, but not the only reason why you would have loss of motion. There’s a million ways to do this. What do you guys think? Who wants to start? I mean, somebody can ramble on a million things, but what do you think is the most important thing to do? A post-op patient comes in to you with limited knee extension. Lenny, why don’t you start with this? What do you look at to determine why, maybe, they have this loss of motion?
Lenny Macrina: Yeah. I mean, usually it’s because they weren’t educated at the beginning on how to keep the range of motion. So, a big portion of my education when I first get somebody in, especially after an ACL, where there’s a lot of pain or a knee replacement, is prop the heel up, allowing that knee to get into extension. The position of comfort is going to be slight flexion. Open-packed position of the knee is about 20 degrees. So you’re going to want to put a pillow under their knee. So education by all means, first, is to get them to understand that getting extension is the most important thing after surgery. You mentioned tone in the hamstrings. Yeah, probably, maybe. Because, they are going to get shortened over time. But, there was a study that came out last year, I think it was Med Science Sports and Exercise, that showed that it was the capsule that gets tight and not necessarily the hamstring. For me, I want to do things that are going to address both hamstring and capsules. So, I’m going to look at how you stretch out capsule or collagen tissue? You need prolonged stretch on the knees. You need prolonged, low-load long duration stretch. So, you need the person to prop the leg up and give a good 15 minutes at a time. We recommend usually 60 minutes total in a day, to get the knee to into full extension, whether it’s beyond 0 or not, and symmetrical to the other side. So, getting the collagen to stretch out, I think, is the key and hamstring stretching, maybe some foam rolling, maybe some soft tissue work.
Mike Reinold: Let me jump in and ask you a question here. A couple things… One, I liked your approach at first. If somebody comes in tight, the first thing you do is blame them. Love it.
Lenny Macrina: Yes.
Mike Reinold: It’s awesome.
Lenny Macrina: It’s not my fault.
Mike Reinold: It’s their fault.
Lenny Macrina: Blame it on them.
Mike Reinold: Make it very aggressive, too. I like that. No. But, I think that was actually an excellent point you made, because everyone’s always looking for the reason. Is this tight? Did that happen? Did this happen? When realistically, sometimes they weren’t educated enough. Maybe they spent a week home after surgery and nobody told them to go straight. So I’m jesting, obviously. But, I think that was actually a really good point, that I like. Tell me about that study though, because remember, in my mind, the hamstrings attach and blend into the capsule, to an extent.
Lenny Macrina: Correct.
Mike Reinold: So, how do they differentiate between the hamstrings and the capsule?
Lenny Macrina: Unfortunately, they use wraps or something on mice. I think it was mice. Because of their biology, it’s very similar to humans. They basically, should put the mice in a cast, their little legs-
Mike Reinold: Dork.
Lenny Macrina: … for a period of time. I know. We appreciate their contributions to research. Then they looked at the collagen under a microscope to see the changes in the elongation of it, versus hamstring. I use it in my courses, as well as our online e-seminar course and anytime I speak. It’s the capsule that we primarily have to address. And how do you stretch out collagen is, you’ve got to get a prolonged stretch in the knee. If we can even get a substantial change, because it is collagen. But, you have a window. A window of opportunity. It’s not like the IT band. It’s this thick, fibrous structure that you need thousands of pounds of force. We can get it back. I think it’s more so, the tight collagen and the tight capsule that the study showed.
Mike Reinold: And let’s assume for the rest of this conversation, we’re talking about a postoperative knee that is not super chronic. Because man, that’s a whole ‘nother conversation.
Mike Reinold: You’re talking about somebody six months out of an ACL, that’s a completely different conversation, in my mind. So, I like that. We’re in the first acute, maybe even subacute, phase, like that. Collagen tissue, shorter intensity or less intensity, longer duration type stretching. I like that. I wanted to ask one question, then you jump in. Lenny brought up, it’s collagen and it’s the capsule. So, talk about prolonged stretching. Does anybody do joint mobs? What do we want to talk about with joint mobs for the knee?
Dave Tilley: Yeah. I mean, joint mobs are probably not going to be changing the capsule tissue or we’re not probably moving the caps around, but it’s going to blend to my point. People hurt, man. If they’re super cranky, the joint is real angry and they’ve been, probably, walking on it for a little bit and starting to get sore and they’re just in a lot of pain. Anything you can do, a little bit, to maybe make them feel comfortable or calm down a little bit. Sometimes the joint mobs makes them relax. They’re just completely chilling out. I think this is, again, the swing of social media is, everyone’s no modalities ever, no passive stuff at all, but five minutes of heat and a little bit joint mob would make someone’s knee range much, much easier. Maybe they’re just sitting down for 10 minutes. Honestly, maybe that’s it. But, that can go a huge way to help your manual therapy.
Lenny Macrina: I can’t tell you how many times I have people like, “Oh, I can heat it. I can ice it,” and they don’t know. And then you maybe heat them, because you want just promote healing and relaxation and maybe a little blood into the area and like, “Wow, that felt amazing.” So whether or not social media says it was bad, if that person says, “I like that,” you’ve got to go with it.
Dave Tilley: Even if you measure five degrees more range of motion by another session, who cares.
Lenny Macrina: They buy in. You saw the objective change. They feel so much better about their knee, they feel better about their situation. It’s a no brainer, despite the social media world saying, “There’s no evidence. All the evidence is negative.”
Mike Reinold: So the funny part is, we call that positional release, because we have to make a fancy phrase for everything. They’re just sitting there and we’ll call it positional relaxation. I mean, there’s a little bit that we can add a little science to it. All right. So I think we’d all agree, with joint mobs, maybe we tell them we’re trying to get them to relax a little bit. But let’s say it’s two weeks out, they’re lacking full knee extension and it’s an ACL. Would you do a joint mob?
Dave Tilley: Yeah.
Dan Pope: I still would.
Mike Reinold: You’d do a joint mob on the knee two weeks out of an ACL reconstruction?
Dan Pope: Well not necessary an ACL, but I’m thinking a post-surgical knee. I would still attempt it. I think there’s still a period of time where you can have effect. But, if I’m trying to not stress the ACL, obviously, I wouldn’t do that. But-
Mike Reinold: Well definitely patella mobs. I meant more tibial femoral. So, if it’s not ligamentous we maybe would. This is good to talk about because you guys get to hear the discussion here. So maybe you’re right. Patella mobs, obviously. Patella’s an actually big one, too.
Dave Tilley: Especially superior, to try to get that last little bit if it’s extension.
Mike Reinold: Especially if you have a patellar tendon graft or maybe even a quad tendon graph, to an extent. Patellar mobility is going to play into this. We’ve got a whole ‘nother realm right there. So, I don’t Know. As a group though, ligamentous injury, we’re not joint mobing, right?
Dave Tilley: Yeah.
Dan Pope: Probably not.
Mike Reinold: All right. Thankfully. That’s good. Otherwise, we’re going to pause this and have a Champion staff meeting. I don’t know. I probably wouldn’t do it with a meniscus either, to be honest with you.
Dan Pope: Be careful with distraction, that’s a thing. There’s some things you probably still can get away with, but obviously, you’re not going to translate and try to tear that ACL.
Dave Tilley: Test the graph.
Mike Reinold: Yeah. Again, probably fine. But again, I think the reason why I brought up joint mobs is, Lenny talked about the collagen tissue and the capsule and stuff like that. I think theoretically, that sustained position, that positional release, that low-load long duration type stretch, is probably better than a joint mob on that. I know there’s a lot of manual therapists out there that would go right to join mobs. I think that’s showing us…. We may use some joint mobs on the right person, at the right time, if it’s to neuromodulate, try to get them to relax and move a little bit better. But, I think there’s other things to do.
Dave Tilley: I think we’ve said on a podcast before, but you have to have a consistency over intensity mindset. Like Lenny said, four sessions of 10 to 15 minutes a day, is better than one day where you’re trying to jam your knee. I mean, I made some mistake as a therapist. They come in, it’s not straight and you’re panicking, like, Oh God, we got to get the straight and you’re really cranking on someone’s knee in one session. It’s probably not the best thing to do, intensity wise, because that person’s going to leave really sore and they’re not going to want to do their exercises later.
Mike Reinold: Right. I like it. Good.
Mike Scaduto: And they further promote tone. They may get some guarding, especially if we’re putting them in a more painful position, trying to gain range of motion. I know Lenny talks about it all the time. A prone hang sometimes will promote more tone in the hamstring, because they feel vulnerable there and they want a guard. So, they’re going to get into more of a flexion contracture. It makes it tougher for them to relax the hamstrings.
Lenny Macrina: I think that’s a good point to know. The question was, what we do. I think that’s good Dr. Scaduto, (@ mikescaduto.com). Is prone hang sup high-low long duration and other things like retro walking on the treadmill or retro cone walking or something like that. I’m a supine. I want them supine. I want them lying down. I want their ankle propped up and I want a light weight, 5-10 pounds, to be pulling their knee into extension and beyond.
Dave Tilley: Above the knee, right?
Lenny Macrina: Above the patella. Yeah. So not squishing the patella versus the prone hang, because of the hamstring getting tight and people just freaking out that their leg is hanging off the table and their pelvis stops twisting out of control. Now, the whole thing just becomes chaotic, I feel like, in people that I’ve tried prone hangs on. The doctors recommend it, so you have to do it and then it’s just… All right, let’s just go back to what I know and trust. And that’s just lying down and working on supine.
Mike Reinold: So we talked about pain, we talked about guarding, we talked about some tone from the surgery and stuff like that. All great. What about swelling?
Dan Pope: Swelling is a point.
Lenny Macrina: Yeah.
Mike Reinold: Right?
Lenny Macrina: So basic.
Mike Reinold: Acute wise, sometimes it’s just swelling.
Lenny Macrina: Takes up volume in the knee. Causes pain. You want to protect the pain. So you-
Mike Reinold: Yeah. And that’s not even an effusions effect on pain. You’re absolutely right. But I mean, we tell everybody there’s not a lot of room in the knee for it to go, for it to pooch out. And what tends to happen is, it tends to pooch out in the back. If you get a big fused knee, obviously it kind of comes all the way around. But in the back, there tends to be a large pooch in that effusion right there and that’s definitely going to be impactful for both flexion and extension in the knee. You see that in both ways.
Mike Reinold: So sometimes, it’s just getting rid of their pain, getting rid of their swelling, getting them more comfortable, so that way they decrease their guarding and then getting them into these positional releases, like this low-load long durations stretching, frequently over time. So if you notice here, we’re doing nothing aggressive, we’re not doing any manipulations. We’d even talked about really not doing that much for joint mobilizations. It’s more about getting rid of the pain and getting rid of the effusion, getting rid of the guarding and getting them into these nice sustained positions, frequently, throughout the day. That’s our first attack.
Mike Reinold: If you’re talking about a chronic person, a whole ‘nother conversation that we won’t get into in this podcast. I’m sure we’ve talked about it. I don’t even know, we’re at like 200 episodes now. I forget what we’ve talked about, but that’s a whole ‘nother conversation. One other question, what about about soft tissue? Nobody said anything about soft tissue. Thoughts?
Dave Tilley: Gastroc maybe. Head to the gastroc or blending in behind the news, as well.
Mike Reinold: I mean, gastroc can be both across the knee. So theoretically, if you’re in a shortened position, those guys get toned up.
Dave Tilley: Not walking.
Mike Reinold: Yeah. I mean, is that a part of it, too? So we would all do that. All right. So let’s summarize. Let’s say you come in, you’re three weeks out of ACL reconstruction and you’re lacking a little bit of knee extension. What are we going to do?
Mike Reinold: First thing we can probably do is hop him up on the table supine. We’re going to probably put a hot pack on their knee and put their heel propped up and let it just slowly sit there 5-10 minutes. See what we get for range of motion. From there, I think we’re all going to probably go soft tissue. We’re probably going to go hamstring, gastroc, but then also effusion based off tissue, if there’s anything going on with the knee. From there, we’re probably going to go patellar mobilizations. Going to do some patellar mobs and then from there, we’re probably going to then try to actively get them engage their knee so that way it goes straight. So, knee extensions, retro cone walking-
Dave Tilley: Quad set.
Mike Reinold: Like Lenny said, even just walking… Or just a quad set. That’s a great point, just a quad set. We’re going to actively get them in that position and then we’re probably going to ice and then we’re probably going to compress it with a wrap or a sleeve, afterwards. Pretty comprehensive. There you go. So, summary in the last minute. But, I like how we brought that all together. Does that make sense? I think everybody wants to jump right into, Oh, this is a problem. I got to be aggressive and do something, where it’s actually pretty simple-
Dave Tilley: Fix it in 10 minutes.
Mike Reinold: … and you take a step back. Awesome. So good. I like it when we can answer a question like that. And we can almost have a little case at the end. So hopefully, maybe you can watch that again. Watch that last minute or two, again. Maybe put it down to 0.75 time speed on the audio there. I talked like Dave on that one. I apologize. But, good question. Hopefully that was a good understanding of our treatment approach, of what we would do with that person.
Mike Reinold: So if you have a question like that, head to mikereinold.com, click on that podcast link, and be sure to fill out the form to ask us anything. Really, we had so many diverse questions. We love hearing them, so keep sending them. We’ll keep answering them and we’ll see you on the next episode.