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Extension Lag Following Knee Surgery

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A common issue after knee surgery is quad weakness that may result in a knee extension lag. This can have many consequences for future strength gains and gait training, so it’s always best to address this quickly.

Here are some strategies we use at Champion when someone has a knee extension lag.

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#AskMikeReinold Episode 269: Extension Lag Following Knee Surgery

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Show Notes


Transcript

Student:
All right. So, we got Tom from New York asking, “Following a knee surgery, like ACL reconstruction what do you do if a patient is having a hard time completing a straight leg raise without extension lag? Would performing the exercise with a brace lock then extension be appropriate?”

Mike Reinold:
Awesome. Yeah. Great question, Tom. Good job, Zach.

Mike Reinold:
Yeah, that’s pretty common, right? That’s definitely something we see. This is probably a pretty good question because I bet you a lot of people see this and it’d be nice to just kind of hear everybody’s tips on what we do.

Mike Reinold:
ACL is probably one of the more common ones, but it really can be from any knee surgery, that knee extension lag where they’re trying to do a straight leg raise, but they don’t have that quad control to lock out the knee and do it straight. I mean, essentially it’s just a sign that the quadricep strength is just not there. Or it’s just not active for that ability to lift that leg straight.

Mike Reinold:
So, what do we got for tips on that? I mean, I think we had a few tricks up our sleeves with that. But who wants to jump in and offer the first tip of advice for what you do with a lag with a straight leg raise?

Lenny Macrina:
Is that what the question is? I’m confused by the question.

Mike Reinold:
Are you serious? I can’t tell if you’re serious.

Lenny Macrina:
It says without an extension lag? So, if they don’t have an extension, is there something else? Am I just not understanding the question?

Mike Reinold:
No, you’re definitely not understanding the question. What do you do if a patient is having a hard time completing a leg raise without lag?

Mike Reinold:
Oh.

Lenny Macrina:
So, without a lag, that means the left knee is straight.

Mike Reinold:
So, you’re criticizing Tom for lack of a comma, I believe? Because I think the comment just changes it. Wow.

Lenny Macrina:
I will assume that they’re having a lag because in the question, it says without an extension lag.

Mike Reinold:
I like this. Grammar police. This is why, by the way, Lenny edits all of our manuscripts, just so you know, when we have publications.

Mike Reinold:
But let’s just assume-

Lenny Macrina:
He has a lag?

Mike Reinold:
… the obvious. And we’ll go from that.

Mike Reinold:
What do you do, Len? I know you have some nuggets of information here for us and not just grammatical critiques. But what do you got?

Lenny Macrina:
I’m just making sure we answered Tom’s question.

Lenny Macrina:
Yeah. I mean, obviously the obvious is going to be using STIM. I would just try to STIM the quads. Some NMES, not TENS or anything like that, but STIM. That can help to facilitate the quads to contract better.

Lenny Macrina:
And then, thinking about reasons why this potentially happening, do they have excessive swelling in the knee joint that could cause some quad inhibition or excessive quad inhibition? So, we need to get the swelling out.

Lenny Macrina:
Patella mobility. Can they get the patella to lock into the trochlea and be able to raise the leg, get the knee straight? That would be another issue.

Lenny Macrina:
You could even try to put them in side lying. So, take gravity out and put them in a side lying position and have them do an abduction raise and then raise out to the side, kind of parallel to the floor. Use gravity as not resisting the leg.

Lenny Macrina:
You could put them in a brace. I don’t often do that cause not everybody has a brace after an ACL surgery. At least what I’ve see, they’d mainly do, but not everybody use a brace, believe it or not. So, you can’t always assume they have a brace.

Mike Reinold:
If you have an extension lag too, oftentimes you still have that in the brace. I mean, these braces aren’t magically locking you out at zero, too.

Lenny Macrina:
Right. Yeah.

Mike Reinold:
That is an issue. So, that’s like a band-aid that’s not like part of the issue.

Lenny Macrina:
Right.

Lenny Macrina:
And I would assist, too. Some people need that little extra push. I’ll hold them by their ankle and give them an assist up. And maybe they do a quad set at the top and really have lock-in while I’m assisting. And I think that can help, as well.

Lenny Macrina:
And just doing a ton of quad sets. If they can’t get that quad to engage and lock the knee straight, then their homework is going to be STIM with quad sets obsessively at home. They’re doing not just two sets of 10, twice a day. They’re doing it all day, every day until something gives. And they’re icing a ton at home, as well.

Lenny Macrina:
Those are my big nuggets for somebody without-

Mike Reinold:
Sorry?

Lenny Macrina:
Nothing.

Mike Reinold:
Without the lag.

Mike Reinold:
I like how you bring up a couple of big topics that actually have nothing to do with the lag, but maybe they’re creating a lag, like the swelling, the pain, the patellar mobility. Especially if you have an ACL with the patellar tendon graft, maybe it hurts in that area when they can track.

Mike Reinold:
So, sometimes it’s not just, how do we fix the lag, but what do you have to work on to get rid of the lag? I really like how you brought that point up.

Mike Reinold:
What else? What do you do, Dan?

Dan Pope:
I think it’s just kind of silly, but I oftentimes I think the straight leg raise might not be coached appropriately. Typically, when I think of coaching, I’m thinking of coaching a snatch or something.

Dan Pope:
But straight leg raise, most folks, their first repetition, you say, kick your leg as straight as you can. First rep actually looks pretty good. They’re struggling. They’re working. Then the next 10 to 15, they just let the knee bend and keep going.

Dan Pope:
One of the things I like to do is just put something underneath the heel so that every single repetition they’ve relaxed fully. They get the knee into extension or hyperextension as much as they can, flex, try and get good quad set, and then raise up. And reset every single repetition just because I find that folks don’t perform their straight leg raise in a way that’s going to reduce the quad lag. They just keep on going with a bent knee and they’re probably not getting the result they want.

Mike Reinold:
Right. And remember it, I think you said that well where, sometimes it’s coaching based. Remember, they’re just trying to get from Point A to point B where it’s just lift their leg up into the air. If you don’t instruct them on how, then sometimes it’s the path of least resistance.

Mike Reinold:
Your hip flexor is in a good spot. They’re just going to raise that leg up and they don’t really care about the position your knee is in. So, that makes it really, really important to really emphasize, “Hey, contract that quad. Squeeze that quad.” Or what would we say in Alabama, we would say, “Mash that quad.”

Lenny Macrina:
Mash that knee straight.

Mike Reinold:
Mash that knee straight, as straight as we can, and then lift that leg up.

Mike Reinold:
And then, what I often do with that coaching cue is, if they start to lose that or they’re starting to get tired, we actually, “Whoa, whoa, stop that rep. Let’s start over and do it again.”

Mike Reinold:
Remember, it’s as much neuromuscular control as it is a strength deficit with that. So, I think that’s huge.

Mike Reinold:
We’ve got to get a video on Instagram of you coaching this, too. I want to see somebody like, maybe they chalk up. Maybe we’re doing some big motivation on this.

Dan Pope:
A whistle.

Mike Reinold:
Exactly. But I think that’s great.

Lenny Macrina:
I do want to add one more thing though, because I’ve seen this a couple times. If this person is having a lag with their leg raises and it’s way out of surgery, something unusual, not just a few weeks, like eight weeks, 12 weeks, and they’re still struggling?

Lenny Macrina:
You’ve got to start thinking about, do they have a femoral nerve block? And is that affecting them? So, is the nerve that innervates the quad not firing appropriately? Or is it a tourniquet thing? Did they use a tourniquet during the surgery? Or did they use a femoral nerve versus an adductor canal block? And that could affect it.

Lenny Macrina:
I’ve seen people have quad issues long-term, like for the rest of their lives, if they’ve had a femoral nerve block that went crazy and now their nerve is not functioning correctly.

Lenny Macrina:
That’s another thing too, depending on where this person is in their rehab. A couple weeks out, not surprising. It can happen. But a couple months out, you start running into other issues.

Lenny Macrina:
So, I would keep that in mind, as well.

Mike Reinold:
I like that. Yeah. That’s good.

Mike Reinold:
Anybody else have any other tips that Lenny and Dan didn’t cover? I mean, this is a pretty straightforward one.

Mike Reinold:
I think the only thing I would add with this is that, maybe sometimes, one thing that I would do is that, Lenny said a lot of quad sets, quad sets, quad sets, but I think sometimes we can do that poorly. Maybe at home, they’re doing it on the couch. So, inherently your butt’s going to sit into the cushion and you’re going to be in a flex knee position on the couch.

Mike Reinold:
You have to really educate them that, “Hey, you’ve got to prop that heel up.” I think Dan mentioned a little bit. Prop that hell up.

Mike Reinold:
Sometimes I like to do a reverse, though. And not everybody has knee extension like recurvatum, like excessive hyperlaxity. But sometimes I just want them to do a quad set and start with their heel on the ground. And then my cue, my coaching cue, is to lift your heel up off the table. That way they’re not really focused on their quad, they’re focused on lifting that heel up. And then, they understand that appreciation of that lockout mechanism.

Mike Reinold:
I’d say that’s just one other thing to do is maybe sometimes change the focus to an external focus with what they’re doing with the movement at the heel and not at the hip. I think sometimes may have an impact, too.

Mike Reinold:
I think we nailed it pretty good. I mean, we talked about some of the external factors. Kevin, you want to add something?

Kevin Coughlin:
Yeah. I just want to say one piece of equipment we have here that I’ve found super helpful for this is M-trigger, the biofeedback.

Kevin Coughlin:
I think to Dan’s point, sometimes these people can do it for one or two repetitions and then they think they’re contracting as hard throughout the whole set. But sometimes just with that visual feedback to see, this is how hard you need to be contracting….

Kevin Coughlin:
Some of the things Lenny mentioned, if they just can’t do it, it’s not going to be as helpful. But I think sometimes, it’s just them learning this is how hard I need to contract my quad during a set of straight leg raises. That visual feedback could be super helpful sometimes.

Lenny Macrina:
That’s a good one. Yeah. Good point.

Mike Reinold:
Yeah. That’s a really good point, too, of getting that feedback and using a biofeedback system, like the M-trigger. That actually makes sense. That’s a good point.

Mike Reinold:
I’m glad you said that because with a question like this, sometimes we miss one or two things because it’s kind of second nature for what we do. But I think that’s a great point.

Mike Reinold:
But again, just to recap quickly. Make sure you’re addressing the underlying things that may be inhibiting that. So, assuming it’s not a nerve block issue, but swelling, pain, patellar mobility, range of motion, maybe they don’t have the full motion-

Lenny Macrina:
Yeah, exactly. Full extension, yep.

Mike Reinold:
You’ve got to nail that down first and then really work on that quad control. You can use neuromuscular stimulation to help at the same time. You can also use biofeedback to actually help them facilitate that contraction on their own. And just really make sure we’re coaching and cuing that.

Mike Reinold:
There’s tons of ways that you can do that. But hopefully some of these tips will help you get that extension lag passed a little bit quicker for somebody post-surgery.

Mike Reinold:
Great question. Appreciate it, Tom. That was good please. In the future, make sure you only submit grammatically correct questions or you will be-

Lenny Macrina:
Sorry.

Mike Reinold:
I don’t know. Maybe I just read quickly, but I thought your question was great, Tom. But thanks so much. I appreciate it. If you have a question like that and aren’t afraid of submitting a grammatical error, please head to Mike Reinold.com. Click on that podcast link. And you can submit as many typos as you want.

Mike Reinold:
I can’t wait to see them. And we’ll see you on a future episode. Thanks so much.

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