A lengthy period of immobilization can really set you behind after knee surgery. People often present with persistent pain and swelling, a loss of mobility, and poor quadriceps control.
But one of the more tricky things to work on is restoring knee flexion.
Here are some of our tips on how to regain knee flexion after a lengthy period of immobilization.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 285: Regaining Knee Flexion Motion After Immobilization
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Show Notes
- Assessing and Treating Loss of Knee Extension Range of Motion
- When to Push Range of Motion After Surgery
Transcript
Student:
Yep, I got it. All right, so Jason from Tennessee says, “I’m working with a medial meniscus repair that is eight weeks out of surgery. The surgeon kept him in a straight leg brace for six weeks. No PT was done during this time. He shows up with limited flexion and extension lag, swelling throughout the knee, very weak quad and hip flexor. I’ve been struggling to get flexion back and keep it. I have tried everything in the book from heel slides, wall slides, manually pushing and even stationary bike. I don’t have a mechanical knee flexion device. Is there anything else that may work, or is this a possible setup for a surgical manipulation?
Mike Reinold:
Nice, great job, Beanie. I like it. Jason, good question. I like how he throws out… He probably listens to the podcast a bit, so he’s going to just throw out that he doesn’t have a mechanical knee flexion device cause he knows Lenny’s going to say that, so that’s perfect. Very smart, Jason, on your end. I like that. Yeah, man. This is a bummer one, right? It sounds like pretty much any complication that you think you may have from a mobilization which is loss of motion, probably like not facilitating a good healing environment, still swollen, poor muscle control, pretty much like everything you could possibly have has happened to this person, right? And that really stinks.
Mike Reinold:
I wonder how this person looked going into surgery. That’s kind of one of the first things I think of which is probably irrelevant to this conversation for Jason cause we are where we are. But I wonder if this person went into surgery behind the gun a little too, which is a deeper conversation. But yeah, this is the one. Why don’t we start with this? Lenny, I feel like you talk to people on Twitter about this topic a little bit. How common is this, that we’re seeing this? I get sometimes like some limitations in range and motion are weight-bearing, but are we still seeing this a good amount throughout the country? I mean, Jason’s in Tennessee. We don’t know if this is Nashville versus in a little bit more remote area. How common is this that we’re seeing this?
Lenny Macrina:
I think it’s more common than we like to believe. I think we got a little spoiled because we have doctors that we’ve worked with in the past, and even currently, that trust us and want to get people in pretty quickly. I think a lot of doctors are still hesitant to send people early on because they want that healing process to occur. They may have had a bad experience previously with a patient or a PT that has ruined a surgery there, and so they just say, “You know what, let me lock you in. We’ll get the motion back eventually, but let’s let this meniscus heal and deal with the ramifications down the road.” Which the ramifications are atrophy, swelling, pain, loss of motion, loss of function. I mean, it’s just disastrous. So yeah, that’s some of my goals on social media is advocate for early motion after a lot of these surgeries, including rotator cuff and ACL with a meniscus repair. So yeah, it stinks for its person, but there is hope.
Mike Reinold:
I guess we don’t know the patient, right? Maybe this patient is somebody that the surgeon is intentionally saying, “I’m going to sacrifice maybe a little bit of mobility to make sure that the repairs there.” Maybe the person’s functional goals aren’t super high. Who knows, right? So we don’t know that. We also don’t know how bad the knee was on the inside, right? Only the doc knows. So I try to give the docs a benefit of the doubt sometimes, anytime I see like a big, a very conservative, cautious type script or protocol from a physician, I tend to take a step back and think, and if we know them, reach out and be like, “Whoa, did something bad happened here?” Like, “Was there something on the inside of the knee that you thought that meniscus repair was really bad or something like that?” So yeah, I like it. All right, so-
Lenny Macrina:
I still think that there’s very few instances though, that you have to immobilize somebody for six weeks. I can see maybe a week, maybe two, if we want to really be conservative. That first post-op recheck like, “Okay, two weeks of heal, get the stitches out, now go to PT.” But for six weeks, that’s pretty aggressive to lock somebody down in a mobilized position, poor person. We get home, just not knowing what’s right, what’s wrong, what to do, and now they have to go to PT and they’ll probably be expected to start running in six weeks cause the protocol says to run at 12 weeks. Who knows.
Mike Reinold:
And I don’t want to get mad right now because I… For some, I feel like my heart rate just went up a little bit for a second here. But what do you think the chances are though, that keeping this person home for eight weeks by themselves, what are the chances are that they do either too much or too little? And too much is probably quite like…. Maybe that’s why he’s all swollen is he’s done nothing appropriate, but is limping around the house trying to do his ADLs and stuff like that. Which is, why wouldn’t you, especially if you’re not in a lot of pains. So, sometimes even just getting in with therapy to be like a little bit of a guide like, “Hey, slow down. Wait, you’re doing what?” Because patients come up with the craziest things like, “Oh, I didn’t realize I couldn’t do that.” Well like yeah, no, of course you can’t do that. You know?
Mike Reinold:
So super interesting. Again, shortsighted, I think again on the physicians that they… Not only do, they’re trying to protect him against doing too much, but they don’t see us as a guide sometimes. I think we could guide this process a little bit more smooth. Anyway, let’s get back to what Jason… Jason doesn’t really care about our feelings right now, Jason cares about the answer to his dang question. And that’s about as close to an explicit episode as we’ve had right there, which is pretty good, as the students know, it’s hard for us, right? So it’s pretty good to go. We’re almost 300 episodes without an explicit thing. But all right, Dave, why don’t you start off here? What do we do with this person right now, cause that’s the real dilemma we’re in. What do we do?
Dave Tilley:
Yeah. I think in this situation, it’s not apples to apples with a couple patients that I have right now, but it’s very similar. So ACL, pretty involved in meniscus injury when the ACL was torn, so it’s a big limit to why he couldn’t start motion pretty aggressively, pretty early, cause it would just hurt a ton. So it’s not like the exact same thing, but Dean and I have been working with him, and I think when he first came to us, his mindset was like motion. I got to do real aggressive motion all the time, get my motion back. His extension was okay, which I know is not a situation here, but his flexion, he was really 30 degrees. Like not even 30 degrees. He was like, “I got to push it. I got to push it.” And he was with somebody else who is not mal-intention, but was like, “Yeah, we got to get that back.”
Dave Tilley:
So for me, from my point of view, I was like, “Listen. For one, what you do for 20 minutes here with me is nothing compared to what you do the other 23 whatever hours of the day. That’s more important that you get into a rhythm and a consistent program of trying to get not just swelling down, but also motion, all that kind of stuff.” So that was my first big educational point was like, “Listen, it’s not about going hard in one session. It’s consistency over intensity. That’s how you get even small gains of range of motion.” But two, more so for me, is when he measured his knee, when we looked at his knee, it was really puffy, really angry. It was swollen. It was really like a lot of fluid inside of it. But also, his patella mobility was very, very poor, I think because of that stiffness in the capsule was maybe irritable.
Dave Tilley:
So not only could he not bend comfortably, but his tibiofemoral joint was not moving because its patellofemoral joint, which is really, really stuck. So I was like, “Listen, man. Let’s just try to get the swelling down. Let’s wear a knee sleeve, let’s get your leg up quite a bit. You’re not working right now. You have someone who can help you out. Let’s try to get the patella mobility up and down.” We did a lot of modalities and help with that heat, whatever. I taught him how to mobilize his own patella. And I think for me it was like, “Let’s just do these very small things, set a timer on your phone, every two hours, give me 10 reps of this and 10 reps of other patellar stuff and a quad straight leg raise type work to try to see if we can help that motion out.
Dave Tilley:
And within two weeks he gained probably 20 to 30 degrees of motion flexion, not because of all the stuff we were going crazy on because I think we were just educating him on basic things to do on his own every single day. So that would be my first big piece of advice is maybe this is a situation where manipulation is going to be needed because of scar tissue, but give it a healthy dose of education and listen, just do basic things consistently and get the knee to calm down. And maybe that will make things more comfortable and a little bit less discomfort when he’s trying to [inaudible 00:10:10].
Mike Reinold:
I like that. And I think the big message I got out of you there too, Dave, was maybe to be a little patient, right? We get this person at week eight and then we all have that little freak out experience where we’re like, “Whoa, they’re super behind. I got to push. I got to push to catch up.” But be a little patient I think could be very critical for that.
Mike Reinold:
What do you think, Kev, you get anything to add to Dave? I mean, obviously Dave covered that really well, but anything like you’d like to add to that?
Kevin Coughlin:
Yeah, I think Dave definitely hit on a lot of the things I was thinking, especially in terms of doing the frequent motion throughout the day. But I wonder too, with this person, if there is still a lot of pain. When they’re at home, they’re just sitting with their leg in extension all day, and I think sometimes you have to find out what position are they putting themselves in, and how can we implement something like deflection exercises throughout the day to prevent that extension stiffness? Cause I think people are afraid of bending their knee when it hurts, so that’s probably contributing to stiffness as well.
Mike Reinold:
Yeah, I like that. They find that comfort zone, right? And that comfort zone’s usually what, give or take 20, maybe 30 degrees in knee flexion, especially if they’re on the couch and the weight to their butt kind of sinks into the cushion and stuff like that. So I would agree, I like that. Anything… Len, Diwesh, you guys [Dewey 00:11:36], in the gym we often incorporate… We work on optimizing movement quite a bit with some of our people like, if you have somebody that’s a little bit stuck with their motion, what do you do in the gym that maybe could help facilitate that a little bit? Maybe not somebody that’s eight weeks out, but maybe we can apply some of those principles to this person?
Diwesh Poudyal:
Yeah. I mean, I definitely don’t think I have anything specific for this particular person.
Mike Reinold:
Right.
Diwesh Poudyal:
But I think that the general concept of getting motion or improving motion, let’s say, cause I’m not in the realm of gaining motion back after surgery. But improving motion, we still tackle it with that frequency over intensity mentality first of all, right? Our goal, whenever we’re trying to do stretches and mobility stuff in the gym is not to take them to an eight out of 10 pain or like mash tissues with lacrosse balls that we hear people doing all the time. That’s only going to make someone a little bit more sympathetic and make them even guard up a little bit more, so we definitely don’t tend to go that route.
Diwesh Poudyal:
We go a little bit more calculated, we’ll do some versions of longer holds for stretches. We do some sort of like [inaudible 00:12:47] back and forth. And then we make sure we add a little bit of loading and motor control on top of it. I think that’s the biggest thing to not forget, at least from a healthy individual’s perspective is if we’re not loading this issue, if we’re not actively doing reps in that range of motion that we’re actually trying to achieve and doing plenty of it for the course of the weeks and months, we’re not really going to make that motion stick. It might be a mobility gain for 20 minutes, 30 minutes an hour, but if we’re not actually providing any loads, it’s not going to stick around at all.
Mike Reinold:
Yeah. And I like how you and Kevin kind of put together… Like Kevin had some good thoughts on maybe if they’re doing too little. I think, Dewey, you even had some do thoughts on if they’re doing too much, right? And we see that all the time. If you were to Google how to gain mobility, you’re going to do probably some aggressive stuff. Maybe some aggressive foam rolling or something that may be not appropriate for that person at the time. So it’s finding that happy medium.
Mike Reinold:
I think the only thing I’d add to this is that, and I think this sinks well with what Dave was saying too a little bit here was that, I wonder if Jason in Tennessee, I wonder if when the person comes in front of you, you look at them and it’s eight weeks and they’re behind in their range of motion, and that is your primary focus because you want to get that motion caught up. You want them to be a little bit better. And you do know it’s going to get harder and harder over time to get that. So I like that motion.
Mike Reinold:
But one thing I think sometimes we take for granted when we read protocols is that the steps before that were probably very critical to get them to the range of motion we wanted at week eight, right? And I think this might be where patients comes in a little bit here, but if you don’t work on the swelling, and you don’t work on the pain control, and you don’t work on the basics of patella mobility, and even soft tissue mobility around the knee at this point, if you don’t do that, I think it’s going to probably be harder to get that emotion over time. So all those exercises we weren’t allowed to do because they weren’t in physical therapy for the first six to eight weeks, I think you still need to go through that process and just say like, “Okay, we may be a little bit behind with range motion, but just forcing it on top of that, I think sometimes maybe challenging.”
Mike Reinold:
And to kind of add to it, Dewey said a little bit, and I know Lenny thinks this way here too, but not contracting the quad for that long plays a big part in not allowing patella mobility and getting out of that normal motion of the patellofemoral joint to unlock that knee flexion range of motion. So being able to engage the quad I think is important too. So like Dewey said, throw some exercises on top of that, make sure we’re still doing quad sets at straight leg raise. It seems so basic, but that actually helps with patella mobility, right?
Mike Reinold:
So it’s not that we’re just doing it for neuromuscular control. It’s like putting it all together, right? So I think that’s, for summary for Jason, I think that’s the big thing is, it is what it is if you get the surgeon sending him that late. I guess resist the urge to rush it if their knees not ready. Some people, eight weeks out, their knee will be ready to be pushed if they’re behind, but this person feels like we need to take a step back. Control the knee like Dave said, right? Make sure that they’re doing the right things around the house like Kevin and Diwesh said, and then really focus on getting back to that range of motion in a week or two when that knee is feeling a little bit better. And I think you’re going to probably have some better results, right? Make sense.
Mike Reinold:
Good question, Jason really appreciate that one. I think that’s something that a lot of people struggle with. So hopefully that’s helpful to everybody. If you have a question like that, again, head to mikereinold.com, click on that podcast link and you can fill out the form to ask us your own question and be sure to head to Apple Podcast, Spotify. Rate, review, subscribe so you get our next episode, and we’ll see you next time. Thanks so much.
