Internal bracing is becoming a very popular procedure with orthopedic surgeons. Repairing ligaments and then augmenting the tissue with an internal brace has shown to be promising throughout the body, including the MCL of the knee.
But, what do you do if there is prolonged stiffness?
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#AskMikeReinold Episode 361: Knee MCL Repair with Internal Brace
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Show Notes
• Evaluate and Treatment of the Knee Masterclass
Transcript
Ben Fugitt:
All right. We got a question from Brenna from North Carolina who says, “I just adopted a patient from a different therapist who had an internal brace for his MCL in his knee. He’s three months out and still struggling with flexion and extension range of motion and also very poor quad. Any experience on internal brace in the knee and wisdom on how I can help with him?”
Mike Reinold:
Awesome. All right. Great question, Ben. Brenna, thanks. Good question from Brenna. I wanted to share this with everybody here. Just man, I think it’s a debatable topic or a conversation at least here.
So, internal bracing. So this is a new augmentation of repairs that is becoming more and more popular in orthopedic surgery. Foot and ankle surgeries. We’re seeing it a ton with Tommy Johns at the elbow. We’re starting to see it with more knees, with MCLs, that sort of thing. And interesting with this knee, with an MCL, we have loss of range of motion at both ends of the spectrum. Both flexion and extension, which, kind of interesting.
But why don’t we start with this? Does anybody have one of these? Has anybody seen one of these here? This is just kind of more speculative here. We see a ton of these in other joints, but not so much the knees, I would say. So what do you guys think? Who wants to start tackling this in terms of… Obviously, they’re looking for advice here. What do you think? Dave, you want to start?
Dave Tilley:
Yeah, it kind of works out where the next series of questions in the journal club, maybe later we have… But I just seem to have a lot of post-op knees right now. I just have an influx of ACL tibial plateau fracture, and I was talking to Lenny about this because two of my people are ACL or tibial plateau. They also have MCL sprains, and they all just tend to really struggle right now with quads. So they kind of have a similar situation, which is all their flexion restrictions are medial joint pain because of the MCL. Their quad is struggling a bit on a straight leg raise, and they’re struggling with flexion range of motion as well.
And I feel like we talk a lot about the research on… Okay, AMI can do icing and this kind of stuff to get the quad going, but that also maybe is going to make flexion struggle if you ice the knee for 20 minutes before you try to bend it. And then when someone has MCL pain, it’s like that’s the limiting factor. You don’t want to rush somebody and make the joint get cranky and angry, but you want to get them going. And so I just feel like when you deal with complex knees that have new surgeries or a lot of things going on, you’re playing this tug-of-war between what’s the most important immediate goal.
And I’ve leaned on Lenny a bit because, okay, well the first thing is like we got to get this person’s motion and get them off crutches and get them comfortable. So maybe you prioritize that and the quad is the next thing to tackle after maybe the motion makes progress, the pain gets down, the swelling is down. That’s only going to make strengthening more comfortable because of the AMI. Swelling is a big indicator of AMI. So maybe you prioritize the most important next domino and you tackle that for a week or two, and just kind of give a little bit in the strength bucket knowing that maybe long-term, strength will come a bit more long-term and it will be a grind, but it’s more important to get the motion going and get the swelling down, and not lose that and get a scar tissue situation then have a really strong quad, but a really stiff leg that’s not functionally useful.
So I just wanted to jump in first because I feel like I’m living through a bit of what Brenna’s going through with all these tough cases that are just a lot of moving pieces together. You’re like, “All right, is it the quad, is it the knee, is it the pain? What do I tackle first?” So yeah, that’d be my suggestion.
Mike Reinold:
Yeah, I think we would all agree range of motion has got to be key here. Maybe this is a stupid question. I don’t want to go off the rails here with this episode here too, but are we overdiagnosing or calling things AMI? I mean, can’t you just be weak because it’s been three months and you don’t have full knee extension, and you haven’t actually had a full quadricep contraction in probably three plus months? And the only reason why I bring that up is that our treatment strategy’s off sometimes, just because you have three months of atrophy versus an actual inhibition? I don’t know. What do you guys think?
Lenny Macrina:
Yeah, I mean, I’ll jump in. Dave talked… Like I said, we talk all the time. And I agree, normally you would do ice. The recent research is ice and get the quads facilitated. But I think in the situation that he’s in, and then Brenna’s situation, I would tell them to heat it. Let’s make the person comfortable. Let’s change their sensory input from a freezing cold, “I’m uncomfortable” position to let’s heat and work on easy motion, multiple bouts of the easy motion. So if the person has lost flexion and extension, and it’s three months out, you’re either going down a surgical route to clean up scar tissue very soon, or you really need to be aggressive with your home program.
And I’ll probably… If I know who this person is, we can communicate off the record here or via phone. But I would say get extension. That’s the priority. Low, long duration type stuff, multiple bouts a day. And then the flexion, same thing. Maybe you get a flexionator, maybe you get them to do… You have to have them do stuff at home multiple times a day. But you’re dealing with… You’re not dealing with just native tissue. You’re dealing with an internal brace. So now you start to wonder, was it locked in too tight? Is the isometry point where it needs to be? Meaning the brace is going to kind of move with the knee and not stiffen up when you get through certain degrees of motion. Because you see that with the elbow. If they lock it down too much and it’s not attached exactly at the isometry point on the joint and fixed at a certain point… And I’m not a surgeon. So flexion extension, if it’s at 30 degrees or 50 degrees where they lock it down, I don’t know what it is for a knee MCL, but if they don’t do it precisely, that internal brace is going to tighten up potentially as you go through certain ranges of motion. It’s not going to stay in its normal length position throughout the range of motion.
And so you might be dealing with that. And so you’ve got to determine what the end feel is, what gains are you making, how are you making it? And you might be just climbing a wall that you’re never going to climb because of the surgical procedure that you may never know is the cause, but it could be the cause. So that’s when you’re communicating with the doctor.
Dave Tilley:
Follow up on that, Len. Would you ever consider long load duration into flexion? Because I have one…
Lenny Macrina:
Yeah.
Dave Tilley:
…With a tricep repair who’s just like, it’s just an uphill battle to get his [inaudible] improved.
Lenny Macrina:
Yeah, definitely.
Dave Tilley:
I wonder if an MCL…
Lenny Macrina:
Yeah. I got a Tommy John right now. We had an internal brace who… He’s got dyna splints working on flexion. For a knee, I’d recommend a flexionator. So you sit in a seat, you crank a device, and it slowly bends your knee. You put a hot pack on your knee and you just sit there for 10, 15 minutes, and it’s going to slowly get that collagen to maybe stretch out and stay permanently elongated. And that’s the key. We’re not getting permanent deformation and elongation of the scarring and collagen tissue. And that’s what you need. You need a permanent elongation.
So the flexionator would be my recommendation. It’s a huge device. It’s like a folding chair with a big device. You sit it in, you crank it, it’s got a hydraulic crank, and you literally just sit at end range position for a period of time, and you slowly crank a little bit more to get a little more flexion. So you’re trying to get that collagen stretched out. It’s going to be a challenge, especially three months out. But there’s hope because it’s only three months out. So it seems like forever. But if it was nine months out, 12 months out and beyond, collagen is tough stretching out that far out after surgery.
Mike Reinold:
When do you start getting nervous? I mean, I’m kind of nervous…
Lenny Macrina:
Now.
Mike Reinold:
…At three months.
Lenny Macrina:
Yeah, now.
Mike Reinold:
I was going to say… Yeah, okay.
Lenny Macrina:
That’s why I said, we’re either talking surgery now or I don’t know… Hopefully, the discussion is beginning to… Especially, I don’t know what the motion is, if it’s 20, not lacking 10 or 15, I’m going to guess to maybe 60, 70. I’m going to guess… If I don’t know this person or what the case is. But that’s typically what you see. We may be getting denied. Maybe 90 or a hundred, but I’ll bet it may not even be that. You’ve got an uphill battle.
Mike Reinold:
So, you can go back and listen to a bunch of episodes and stuff and hear how we deal with stiffness postoperative.
Let’s switch gears here, a smidge here, about theoretically here, the internal brace concept. Let’s assume, just for the sake of answering this question, that this is an over-constrained joint surgically, and it’s being over-constrained by the augmentation to the repair that is designed to create stability in the injury. It’s 12 weeks, you don’t have range of motion in both directions.
Lenny Macrina:
Yeah.
Mike Reinold:
How hard do you push?
Lenny Macrina:
It depends. I would want to make sure that they had an X-ray, that they don’t have any kind of heterotopic ossification. Because that can happen. We see that in the elbow. It might be a little different with a knee than an elbow. But I’m not killing them, but we need to be somewhat aggressive. But I think the multiple bouts of easier motion throughout the day is going to be your key so you’re not really aggravating the tissue. You know what I mean? That’s the key. They can come to PT with me for an hour or whatever, but they need, literally, the other 16 hours that they’re awake, they are trying to do something.
Mike Reinold:
Yeah, makes sense.
Lenny Macrina:
That’s going to be the key.
Mike Reinold:
I almost always say that to people. If you’re that stiff, I think your number one thing is always just like you need to be doing more range of motion throughout the day, like hourly type thing. But Dan, what do you think?
Dan Pope:
Yeah, just one more thing, and I believe I learned from you guys, is that I think you can kind of tell how folks are doing from session to session, day to day, and that can dictate a little bit how hard you push.
I think one of the issues, if you push too hard, sometimes they go backwards, they lose range of motion, gets too painful, too sore. So I think we’re usually proponents of “let’s do a lot of frequent motion throughout the course of the day.” I’ll tell people every hour, do range of motion. We’ll see if we’re making progress. And I might be a little more aggressive and see how they respond to it. So I try maybe a little more aggressive range of motion, joint modes, whatever it is. If it’s not a knee, somewhere else, and see how they behave, see how it goes next session, see how their pain levels are, see how their function is. So if things are progressing and we’re being more aggressive, I think that’s good. But if you’re being more aggressive, they’re getting worse, I think that’s probably a bad thing. But that’s probably one of the ways I would go about figuring out how hard to push or how much I have to back off.
Lenny Macrina:
These MCL scar down. This is the issue. This is why pre-surgery, if they have a grade one, a grade two, you calm the knee down and don’t jump into an ACL surgery with a grade one, a grade two. This is a grade three that needed extra stabilization. They scar down. And I imagine either early on, they were too conservative, maybe the protocol was too conservative, or there was a lot of pain, and the person was fearful.
So who knows what the personality is of the person receiving this treatment from Brenna. And at this point, they’re probably beating down mentally from everything and probably very fearful to get their knee moving. So you’re dealing with that too. So you got to play that game and make them feel comfortable mentally about it. But the MCL scar down. Lateral side knees… I’ve talked about this in the past. Lateral side of stuff, LETs like we’ve talked about, Dave, swell up. Painful swelling, MCL side, medial side, scar down pain. Those are the kind of general principles of the knee joint.
Mike Reinold:
Yeah, pretty common. And I would say going back to even my own question here a little bit, it’s 12 weeks. I mean, I think you have to push. I guess there’s some fear. Again, let’s assume it’s an over-constrained joint, just for the sake of answering this question. What do you do if it’s an over-constrained joint surgically? At 12 weeks, I think you got to push. I’ve had this question about elbows, and I’ve talked to all the best elbow surgeons around the country, and they say push when this happens. So, you know, something to keep in mind.
I don’t think we’re a hundred percent sure why these internal braces work, and I know… I think we have a decent understanding, but some people think it’s the internal brace that’s working. Some people I know just think that the internal brace creates integrity of the repair and keeps that repair tissue together longer, so that way maybe you get a better repair over time.
So I think there’s… You’re not going to function with a range of motion loss, especially with knee extension. You’re never going to get quad back if you don’t have your knee extension. So if you don’t start pushing now, I think you’re out of time. When do you really panic? So let’s say the doctors, or say they haven’t even gone back. So it’s 12 weeks. When do you say, “Hey, you got to go back to the doctor.” Obviously, we’re going to start pushing. She just adopted this person. Do you give it a month? Do you give it two months? What do you think?
Lenny Macrina:
You send them back to the doctor.
Mike Reinold:
Just now…
Lenny Macrina:
Usually they have a 2-week, a 6-week and a 12-week follow-up. So you’re hoping right around now, they’re about to have another follow-up. You’ve inherited the case. You’re doing your assessments, you’re talking to the person, you’re trying to develop a rapport with the person. And I think your professional opinion at this point is, “I think we need another look. We need another potential, another intervention, or just let’s get the doctor’s opinion on this. Let’s get an X-ray, MRI, or something that’s going to give us more information on what’s going on in that knee joint to help me out so I can push appropriately.” Yeah.
Mike Reinold:
Yeah, that makes sense. I got to say, with these internal braces, the doctors are loving them. They’re excited about them. As a rehab person in the background, they’re different. They feel different, they act different. They’re different. So this is something new. We’ve been doing this for a really long time, and the experiences that we’re having with these patients postoperatively are different. I’m not saying good or bad, they’re just different. So I think we need to learn to push a little bit.
I was very nervous with the Tommy Johns with these to push, but then I talked to all the docs, and they’re just like “push” or otherwise you’re going to lose that motion over time. So they have confidence in the integrity of these repairs. So, that made me feel a little bit better. But usually with just a reconstruction you don’t have… It’s a different pliability to the tissue, I guess. So this is a completely different feel for us. So we’re all learning, Brenna. We’re all going through this together. I think we’re going to have some that get too tight, just like we have with other joints, and you’re going to have some that go perfect until we just kind of find that happy ground.
So anyway, good question, Brenna. Thanks for submitting. If you have a question like that, head to mikereinold.com. Click on that podcast link and be sure to subscribe to the podcast so you can get updates on our future episodes. Thanks so much.
