Restoring full knee extension after ACL reconstruction surgery is one of the most important goals in the early phase of rehabilitation.
In this podcast episode, we talk about why people sometimes lose extension range of motion, and some of our tips on what to do when this occurs.
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#AskMikeReinold Episode 311: Restoring Knee Extension Range of Motion After ACL Surgery
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Chris from England: “Ahat are some tips you would give for restoring full knee extension after ACL surgery? I see many patients around the five week mark that have a loss of motion that I would like to avoid.”
I want to avoid those people too.
I like it, right? Yeah, I mean, that’s a good question. So nobody wants to have a loss of extension after ACL surgery. That’s one of our primary goals that we always have after surgery is making sure that we get that as soon as we can. So let’s try this… Chris, I’ll try to lead the discussion a little bit. Before we get into what we do exactly, I don’t know, how often do you see people with loss of extension three, four, or five weeks out? I mean, is that a common thing? Who wants to tackle that part of the question?
I would say it’s uncommon but unfortunate when it does happen. I would say the majority of people… Maybe it’s our relationship with doctors, and they send them early and we see them pre-op, or we educate them pretty well and we’re like, as soon as you can possibly get your leg on a prop straight, please do so. I would say 75 to 80% across the clinic are pretty good. And then maybe you have the one who is sore or not the most compliant, or doc doesn’t maybe feel comfortable with PT until really late and they get a little sticky.
Right. Yeah, that’s one of the first things I thought of too, Dave, but when I read this question, was that perhaps if this person’s seeing this recurring, maybe there’s a consistency there, right? Because you’re always going to have somebody, right? There’s always going to be a patient that gets some tightness of their knee that it just happens. It’s the way things are. Everybody’s a little different. But if you’re seeing this recurring, then I do wonder, is it a limitation too early from the surgeon’s perspective? Are we not emphasizing that early enough? Is it maybe they need a pre-op session for that person? But yeah, I thought that was kind of interesting. Len, five weeks out. Why is somebody typically tight five weeks out? What are some of the reasons?
Yeah, I mean I was thinking what Tilley said. Is there a system issue? Are they not being told in the hospital or after surgery what they need to do? Meaning prop something up under their ankle and just begin to work on that passive extension, the weight of the leg, just pushing down. If they’re not told that, maybe they’re going home and putting something under their knee as a position of comfort to create that little flexion in the knee and then it just snowballs after that, or if the protocol says don’t stop PT for one or two weeks and they’re just sitting at home. So many different reasonings or potential issues that could occur. I seem to not have an issue. I can’t remember. It’s just been a while. If they do begin to lose it a little, I am pretty aggressive with it in getting it back, meaning I am instructive and I’m really on the family, the parents, the kid, whoever it is to get aggressive at home, you need to begin working on extension at home even more so than they’re doing because we’re missing something.
So at five weeks out, if they’re losing extension, I’m thinking there’s a system issue, and then what’s the limitation? Is it pain? Then we get their pain controlled better? Is it a fear and just get them more comfortable doing the whole thing and maybe you get work… Play your Jedi mind tricks and play your mind games with them a little. I think that’s usually the case as well. There’s just a lot of fear. Is it a dissection issue? This was a surgeon, is this one surgeon, they’re aggressive in how they handle the knee and how they dissect tissue. Because I’ve seen certain surgeons even that I get, the patients are in a lot more pain than other surgeons.
It’s the same surgery, it’s the same exact thing. What is going on? So I think there’s so many different factors. I think you just need to recognize it and get aggressive early on with getting that hyperextension, prop the ankle up, maybe even a little ankle weight above their kneecap. I think that’s well-documented. And then go from there. I’ll let other people talk.
I like that though. Good stuff though, Len. I mean it’s not always something mechanically, for example, it’s not always something like, oh, your kneecap’s not moving or something like that. I like the concept of pain and even just fear and the person not knowing like, oh, am I supposed to get my knee straight? Right? Sometimes it’s like us in our golf swing, it’s like, oh, that’s where I’m supposed to put my hands. Sometimes the person just doesn’t know. But all right, who else wants to jump in? I want to talk a little bit more about the strategies that we do with somebody that is tight, obviously, I think that’s important, but who wants to jump in? Dan, you got something?
I was going to say. I think that we often see knees that have had multiple surgeries. I think of the past five patients I’ve had have had multiple ACLs and sometimes it’s on both sides too, so you don’t even know what their normal actually is and you’re kind of left guessing, I don’t know if this is stiff or this is actually your normal because we don’t have a good comparison on the other side. Sometimes the surgical side is better than the other side. So it becomes a little bit confusing, I think, a little bit challenging from that perspective. So I think it’s just good to keep in mind what are the prior surgeries that this patient had in the past, and are you looking at normal range of motion just by looking at the other side?
Yeah, that’s a really good point too. And the more complicated the procedure, the more other surgical procedures that they do at the same time, meniscus, cartilage, those sorts of things, other ligaments, you’re definitely going to have that. So good point. I don’t know, who else wants to jump in here? Mike, Lisa, anybody? What do you do now? So somebody’s tight. What are some things? Lenny talked about and Dave talked about a little bit here, just getting them… Let’s just teach them, hey, you got to get your legs straight more often throughout the day. What other things do you do when you have somebody with a loss of knee extension? Mike, you want to start?
Yeah, I would say the big thing postoperatively is we really want to control and monitor swelling. So I’m definitely doing circumference measurements. I’m doing the sweep test every time they come in. I’m looking for changes in swelling and how that’s impacting their range of motion, especially as they’re getting up to do more walking around the house, sometimes people will start to get a little more swollen. So I’m really monitoring swelling then doing techniques to try and help with some swelling. And I should kind of clarify, also looking at joint effusion with the sweep test swelling within the joint. Then from there, as Lenny mentioned, kind of like a low load long duration stretch into knee extension with the heel propped up, maybe adding an ankle weight above the patella, working on patellar mobs, superior inferior direction, and then starting to work on some active knee extension in the long sitting position first, trying to get some quad control.
I like that. Two big things that I really liked about that, one was the swelling control concept because oftentimes maybe something’s going on, maybe they’re doing too much around the house, maybe they’re not doing their exercises like they’re supposed to, whatever it may be. If they’re constantly struggling with their swelling going up and down for whatever reason, either within or outside of their control, then yeah, that’s going to have a dramatic impact on their range of motion. So that should be a big priority. I like that. But I like what you just said there at the end though, the act of quad control, and I think that’s sometimes it’s something that we miss.
It’s not always just a passive loss of motion. I mean, we also have to get that quadriceps to fire, to get that patellar fire to move, to get that patellar tendon to feel some tension and to get the tibial mortar joint to glide. So I think that’s a good point that I think not a lot of people understand is it’s not just, “oh, what stretch do I need to do or what mobility do I need to do?” Sometimes it’s also just getting them going. Right? Lisa, what else? Anything else you do different or anything else you want to add to that mix? That was a lot.
That was a lot of things. I feel like I’m usually just substitute teacher for ACL people, which is fun. I get to kind of peek in on whatever part people are on. But I will say I got to hang with one of Lenny’s ACLs last week when he was on vacation and he came in and was super pumped to tell me how much time he’d spent hanging an extension. So it was like very telling of this “hammer at home.” It is your job when you are at home to do these things. It was the first thing he was very excited to tell me. He was like, “I think my extension’s better.” I spent this time and even he had an early morning appointment and he already hung out in extension for a while before he came into PT.
So studying for the test, I like it.
Yeah, I like that.
I will say if I may, great point, Lisa, that he was pumped that he did it. There is a world out there, believe it or not, for the listeners, that some surgeons, even PTs are afraid and say it’s bad to get hyperextension. And I would just want to reiterate that it’s not bad to get hyper… When we say hyperextension, that term I get yelled at on social media if I use the term hyperextension, people will just say it’s extension. It’s extension beyond zero and matches the other needs.
Wait, what are we yelling about that now? That’s something else.
I have gymnasts that have 15 degrees of hyperextension. People are like 30 degrees of hyperextension.
Right, how much hyperextension do you get? Do you return all of that hyperextension? Because as Dan said, a lot of people have had numerous surgeries on their knees so you don’t know what normal is for that person. If you do know what normal is, the goal is to eventually get symmetrical hyperextension in both of their knees, but not immediately. So if they have 10 degrees of hyperextension on their nonsurgical knee and that’s their normal, I’d probably get three or four or five at the most kind of early on, and kind of hover there and then let the motion come naturally after that.
I don’t want to get 10 immediately because then that 10 becomes 15 as they start doing functional stuff. Now they have a stretched out graft. You got to be careful. So I would say in the hyper relaxed person, don’t be too aggressive with their extension. It’s going to come back. And the person that has that three degrees of hyperextension, I would try to get it pretty quickly, maybe to zero, and the last few degrees will eventually come. But you can really keep an eye on that because it will kind of drift back into a flexion contraction. So that tight person… So differences in the loose person with the tight person.
How does one of your athletes with 20 degrees past extension, I don’t want to trigger anybody… hyperextension. Sorry, but that sounds terrible by the way. All right. Anyway, 20 degrees of extension, how do they feel if they only have five degrees across the extension? How does that person feel?
The knee doesn’t feel right. They walk with a limp. Their quads don’t come back if that’s long-term. I’m talking like you’re now eight months out and you intentionally got them to zero and stopped because the doc said don’t go beyond zero or you read something that said don’t go beyond zero. They don’t feel right. They don’t walk right. Their quads don’t feel right. Just doesn’t feel right to them.
A lot of gymnastics too needs a very straight-legged bound, like think about just doing pogo hops and plays. So stand up where you are and bend one knee 10 degrees and then hop.
Exactly. It doesn’t make sense. And there are studies that show if you get the hyperextension back, it does not affect outcomes. So Don Shelbourne out of Indianapolis has shown that. So if you get the hyperextension back and get symmetry, that’s a huge indicator of a positive outcome. They’re going to do better than not getting the hyperextension back. They actually get OA in their knee more likely or quicker than not getting hyperextension back, so you got to get it back, in conclusion.
Let’s mix it up. I want to get one more perspective from the strength coaches just quickly here. So somebody that is 4, 5, 6 months after ACL reconstruction or heck, we even see people years out, that they had it a few years ago and didn’t even realize they didn’t have it all back. Tell me a little bit about the importance of that for you because obviously Dave just brought up a really good point. If you’re trying to do athletic movements and you don’t have full hyperextension, if you don’t have the ability to lock out your knee, right, that’s going to impact triple extension, that’s going to impact your ability to produce power. So tell me a little bit from the strength coach’s perspective of why that’s a detriment and why you see that cause problems in people in the gym. Who wants to start? Diwesh do you want to start?
Yeah, I mean it’s as simple like you said of it. It affects triple extension in all of our power producing activities so it’s going to limit jumping, it’s going to limit sprinting, it’s going to limit aspects of cutting and changing direction and stuff. When they get back into training, let’s say in a gym setting and you do all these activities with suboptimal levels of full hyperextension, or extension we’ll call it so we don’t get in trouble, but if we do repetitive motions with not full extension on one side, but then extension on the other side, then we’re going to have funky mechanics for a long, long time. And then it’s obviously going to impact the outcomes and the outputs of sprinting, jumping, any explosive movement. So yeah, it’ll for sure come up and we’ve seen it.
Yeah, for sure. Jonah, from your perspective, how does somebody… You have somebody down the road that doesn’t quite have that, what are some of the things that you’re going to see with them just trying to get through their training programs and their workouts? Can they get strong? Can they get powerful? What do you see?
I would say a lot of just the kind of achiness and stuff that Lenny was talking about for the people who are way longer out, where they end up just not feeling as good when they’re doing stuff, which makes it that much harder to push everything and it can end up being something that’s just kind of constantly on their mind. Similar, but we see it a lot with Tommy John guys who don’t get full extension back in their elbow where everything they do, they’re like, oh, I can’t go all the way down on a pull-up or something like that, or whatever it is, for a breathing drill or hang, anything they’re setting up slightly offset because one of their elbows doesn’t fully extend and it’s on their mind for absolutely everything they do, which I imagine is even that much worse when it’s an ACL and it’s your legs because your feet are in contact with the ground on everything. So I think it just mentally is challenging as well.
Yeah, makes sense. So awesome. So good stuff. Hopefully that helps Chris, we’re big believers in making sure that they get this back right away, so your first step is to work on this week one or week zero, I don’t know. I don’t know what we’re supposed to call anything anymore, but make sure you’re working on this stuff right away so that way you don’t have any of these issues going forward because there’s going to be some repercussions. So great question. Thanks so much. If you have a question like that, head to mikereinold.com, click on that podcast link, and be sure to go to Apple Podcast, Spotify, wherever you listen to us to rate, review, and subscribe. We’d really appreciate it. Thanks so much. See you in the next episode.