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Loss of Flexion Range of Motion after ACL Reconstruction

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You’ve probably heard us talk about how preventing a loss of knee extension range of motion is important after ACL reconstruction, right?

Well, what about flexion? It happens.

Check out this week’s podcast to learn more about how we prevent and treat a loss of knee flexion.

To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 250: Loss of Flexion Range of Motion after ACL Reconstruction

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Show Notes


Transcript

Mike Reinold:
And Max asks, “Hi, I’m a long time listener, first time asker.” I like that. That’s funny. “We’ve seen an increase in ACL reconstructions in high school age athletes. I have two right now that are quad tendon repairs, both are volleyball players. They’re between eight and 12 weeks out, but seem to be getting stuck with knee flexion range of motion,” flexion, interesting. We’ll talk about that. “I was wondering if you have any advice or thoughts on progressing knee range of motion that seems to have plateaued. And what are your thoughts on manipulation under anesthesia on this?”

Mike Reinold:
So let’s see, all right. So to summarize quickly for Max here, lot more ACLs in his clinic, happens to have some quad tendons now. So maybe one of his local physicians is starting to use quad tendon repairs a little bit more or reconstructions a little bit more, which is fine. Maybe Lenny can chat briefly on if he thinks the quad tendon has anything to do with that. But really I think what the big issue is here is we’re getting eight to 12 weeks out and we seem to be getting stuck in knee flexion range of motion. So I don’t know when, Len, why don’t we start with that. Do you think this has anything to do with the fact that it’s a quad tendon? Do you find that you have a harder time getting knee flexion with quad tendon repairs?

Lenny Macrina:
No. No, definitely, no. I’m confused. So that’s when maybe it’s a surgical technique thing. Maybe it was tightening of the graft. That would be probably more extension, but no, I haven’t had [crosstalk 00:03:43].

Mike Reinold:
You could lose flexion if-

Lenny Macrina:
I guess it could. Yeah, you could.

Mike Reinold:
If the tunnel placement or the graft tensioning is a little off, that could be …

Lenny Macrina:
Yeah. What I’ve seen is loss of extension because the quad tendon graft gets too big. It’s a huge graft. So it takes up that small, notch space in the knee. And I’ve seen docs have to go in and do a notchplasty to free up that graft that’s pinching, but that was because they were losing extension and there was no cyclops lesion present. So maybe it is affecting their flexion. Doctors don’t seem to like to do notchplasties, but me growing up as a PT in Birmingham, they did notchplasties on everybody and thought it was beneficial.

Lenny Macrina:
So when you’re talking a notchplasty, you’re talking about taking out the bone that’s on the intercondylar notch of the femur to create more space for the graft to go in at that angle. So doctors don’t really do that, at least up here in Boston. So I’ve seen a couple of instances where you have this big voluminous, is that the word, quad tendon, which is a huge graft compared to a hamstring or patella tendon. And it takes up too much space, and now you start getting a little pinching of that graft and you start losing motion. So that could be that. Maybe if they do do a scope, then they may find that’s what’s going on in there.

Lenny Macrina:
But to get the flexion back, it’s just going to be repetitive bouts of flexion. So soft tissue to the quad, soft tissue to the hamstrings, passive motion. I put a video out on YouTube about trying to work on prone quad flexibility with putting your hand kind of in the back of their knee and giving a little anterior tibial force to create, basically putting the tibia in a different position and be able to get a prone flexion stretch that way in their quads. But without knowing the exact numbers, if they have 120 degrees, I wouldn’t be worried. If they have 90 degrees of flexion, yeah, then I’d be worried. And you start talking about maybe, I wouldn’t say a manip, but maybe manlike a debridement.

Mike Reinold:
Yeah, And that’s part of what Max asked in his question here too.

Lenny Macrina:
Right.

Mike Reinold:
So let’s harp on the quad tendon then just real quick for a second. So is there anything just with the quad tendon obviously being part of the extensor mechanism, is there anything that could become, we talked a lot about the graft within the notch. What about from the donor site, from the quad tendon? Anybody have any experience with that?

Lenny Macrina:
Again, I haven’t seen anything. I guess it could because it is an extensor and it will limit flexion if it gets scarred down, but I haven’t seen, me personally in my cases, if that’s been an issue. Because I work on scar tissue mobility. I’m working on soft tissue mobility. I’m working on patellar mobility. And I’m relatively aggressive with my motion early on so I don’t want it to be an issue down the road. I know where the path could go and I avoid it.

Mike Reinold:
Right, that makes sense. So I would say from our experience then, Max, and anyone can jump in on this. We’ll kind of shift gears on the question here, but I’m not necessarily sure that the quad tendon has anything to do with it, but there’s a chance. It’s a thicker tendon, right? There’s a chance. If you’re starting to find that maybe there’s a pattern, right? Maybe it’s like one physician that is having some of these loss of range of motion issues, that’s a pattern, right? That could be it. Is it only with your quad tendon grafts with that physician? That’s a pattern, right? And you kind of start looking into this.

Mike Reinold:
These might be some good conversations to have with the physician in a non-confrontational way, right? You don’t want to say like, hey, all your patients stink, right? No, just be like, we seem to be struggling with knee flexion range of motion. Is there anything technique wise that we need to know of? Maybe you need to make an adjustment with these people that you want to go a little bit faster with knee flexion range of motion for them, right, because you know that they’re prone to get tight with this physician, with this procedure, for example. Interesting. So I think we’ll start off by first just kind of nailing that and saying, I don’t know if there’s necessarily something that is inherently prone to losing that range of motion.

Mike Reinold:
After we’ve gotten that off the plate, now, let’s help Max out a little bit. So anybody else want to jump in now, what do you recommend Max do now, right? He’s got people that are two, three months out that are losing motion. What do you recommend Max do now? And then Lenny kind of alluded to it, but how do we minimize this from happening in the future? Dave?

Dave Tilley:
Yeah, I was going to say a mistake I made as a younger clinician was kind of thinking that whatever happened two times a week for 30 minutes was going to counterbalance the other 40 to 50 hours they’re awake trying to work on their knee motion when they’re at home. So I think I’ve learned this a lot from you guys is my past self I would go a little bit more aggressive in the clinic, think we got to get motion, we got to get motion, and then they wouldn’t really be extensive enough at their home program. And so I think sometimes backing off on how hard you’re going in the clinic, and then just consistently applying a lot of motion throughout the day is way better.

Dave Tilley:
So we’ll tell people like 10 knee bends an hour, right, for every hour that you can possibly do it. If you’re sitting at school. If you’re sitting at home. If you’re just propped up watching TV. I think that’s probably going to be a better outcome. And I think the research on stretching and what range of motion changes have for the knee or any joint in general are probably going to be more comfortable and tolerable for that person than blasting on their knee and trying to really bend it like crazy in the clinic. Then leave with an angry knee, and then now don’t want to do motion at home or the next day because they’re sore. So that’s just my two cents.

Mike Reinold:
Yeah, that’s a good point. I like that. Mike, how about you?

Mike Scaduto:
Yeah, I would say from an in the clinic perspective, at eight to 12 weeks out, I’d definitely still be looking at swelling and really working on swelling management. If the knee is swollen, it’s just going to get a little bit stiffer. And then definitely looking at patellar mobility still. If they have a lack in the superior inferior glide of the patellar that could affect their flexion range of motion. So those are two basic things I’d make sure that we’re definitely nailing. And then like Lenny said, and I think Dave said as well, just consistent bouts of seated range of motion off the edge of the table, passive range. And just doing that for a pretty long duration in the clinic, not a long duration stretch, but doing a lot of repetitions of flexion range of motion in the clinic would kind of be my strategy. Make sure we’re nailing all those basic things early on.

Mike Reinold:
Right. Good pivot, right? You realize, look, it’s 12 weeks out. There’s lots that you need to do with this person, but maybe their primary thing that they need your hands for is to get that range of motion back. So maybe focus a little bit more time on that. It’s interesting, you mentioned patellar mobilizations, which I thought was pretty good too. With a quad tendon repair, maybe using the quad tendon, you didn’t focus quite enough on patellar mobility. That might be part of it. Yeah, I like that. Dan Pope, what do you think?

Dan Pope:
Sure. I’m just going to add to what Mike said. I think swelling can be really big. If you have a lot of swelling I think that’s big for decreasing flexion range of motion. Especially for a lot of folks you’re battling a lot of swelling further along the rehab process, I think a big reason why people have a lot of swelling is maybe too much exercise or maybe the individual is doing too much walking on their own. They’re doing too much activity on one given day. So I find myself doing a lot of counseling for folks to try to break up their activity across a week, wearing a pedometer, make sure not doing too much walking on any specific day. And if I have to look at some of my exercises because they’re creating too much swelling, I might pull back on those to make sure you’re getting the range of motion and progress well over time.

Mike Reinold:
I like it. That’s good. All right. Dave, you got a little bit more to add.

Dave Tilley:
One more thing is I think oftentimes if the exercise dosages, like Dan’s saying, sometimes loaded movements can really reinforce what they have or what they’re gaining. So finding exercises that don’t hurt, that aren’t painful, like partial arch box squats or eccentric lowers, I think sometimes the actual eccentric loading is actually really important to remodel some of that tissue and make it stick comfortably.

Mike Reinold:
I like that. What’s up Mike?

Lenny Macrina:
Oh, go ahead Mike.

Mike Scaduto:
Yeah, well, I just kind of had a question. I know we covered this topic a long time ago, but someone asked about doing joint mobes on the knee post ACL surgery. Do you think this would be a case where we would do any joint mobes on this person? Tibiofemoral or not patellofemoral?

Mike Reinold:
I guess I’d throw it out to the group too, as a secondary part of that. Do we think that the joint is what’s limiting his range of motion?

Mike Scaduto:
You really have to pay attention to end-feel and all that, quantity and quality of motion.

Mike Reinold:
I don’t know. I’ve personally never done joint mobes on a post-op ACL other than patella. We always get our range of motion back. I don’t know, does anybody think that’s needed.

Lenny Macrina:
Yeah, I agree. I see a lot of people doing internal rotation glides and actually trying to get the screw home mechanism for extension and all that. But I haven’t done it and I never really have an issue, but I don’t know how much it’s doing. And I don’t know if it is a joint mobility thing. It could be at eight, 12 weeks out the joint capitals tend to get a little tight. It could be, but I still think the low hanging fruit is all the other stuff. I’d also be curious if this person, which we don’t know in the details, we don’t even know how tight they are, if they’re truly tight, but did they have a meniscal repair where the doctor limited them to 90 degrees of flexion for four or six weeks, which seems to be the trend. That’s going to really put somebody behind too because you go 90 degrees. They get that at like 10 days post-op at the most. And now you’re sitting there waiting for time to go by to be able to get the rest of that motion back, and they do get stiff. So I wonder if there’s a protocol issue as well, besides a surgical or any other kind of issue that’s lending to these people that are getting tight.

Mike Reinold:
That makes sense to, again, another thing about is there a pattern developing here in people that are being limited with their range of motion. All right. Last part of Max’s question though is what are our thoughts on a manipulation for this person? I don’t know. Who’s dealt with that? Anybody want to jump in on that?

Lenny Macrina:
I would say maybe a scope. If you’re still at 12 weeks and they’re struggling, they’re young people, they should get their motion back over time. But maybe a scope if they have, obviously, a bad end-feel and they’re still struggling, and you’re not making any gains. Maybe a scope to go in there and debride it out and see if there’s a notch impingement by the graft or something like that and they have to do a notchplasty. That would be a surgical decision. Not against it, I’ve seen it. I’ve had some people in my career have to do that, but it’s definitely few and far between.

Mike Reinold:
Would you rather scope to clean out a little bit or would you try just a manipulation with a eight, 10, 12 week ACL reconstruction?

Lenny Macrina:
Yeah, I think from what I’ve seen, it’s typically a scope. I think it’s going to be doctor preference.

Mike Reinold:
Yeah, I feel like most physicians would probably rather scope that versus a total knee replacement at 12 weeks or something. I feel like the physician’s probably a little bit more comfortable with being aggressive with that total knee replacement at that point.

Lenny Macrina:
Yes.

Mike Reinold:
Awesome. All right. So Max, I think in summary, look for some patterns here. You might have some patterns. And these may be bigger things than us, right? This may have to do a little bit with the physician preferences and techniques, and protocols, and stuff like that. So obviously keep that in mind. But on your end, obviously take some of the tips that everybody kind of gave you in terms of how to make sure that we’re restoring motion early and make sure we’re doing with these patients both at home and in the clinic. And hopefully I think now in the future, which I think this is a good maybe learning experience for you, in the future you’re like, all right, these patients are prone to lose knee flexion. What can I do to be a little bit more proactive to prevent that?

Mike Reinold:
I think these are the things that we’ve all been through, right, and have changed the way we practice because we don’t want this to happen and we’ve seen it happen. So it changes you. Great stuff, Max. I appreciate it. If you have a question like that, head to MikeReinold.com, click on that podcast link and be sure to head to iTunes and Spotify, and rate and review and subscribe to our podcast so we can see you on the next episode. Thank you so much.

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