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Restoring Knee Hyperextension Range of Motion

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On this episode of the #AskMikeReinold show, we talk about our current thoughts on restoring knee hyperextension range of motion after surgery. We’ll cover how much we try to restore and what may influence our thought process. To view more episodes, subscribe, and ask your questions, go to

#AskMikeReinold Episode 215: Restoring Knee Hyperextension Range of Motion

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Show Notes


Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about restoring hyperextension after knee surgery.

Mike Reinold: Let’s see. Lynn from Arkansas said, or asks, “What should the goal be for knee extension post knee surgery, when the contralateral knee has excessive hyper extension?”

Lenny Macrina: Whoa!

Mike Reinold: It’s a good question. I feel like Lenny and I’s opinions, I don’t want to say change, because that seems wrong. I think they’ve evolved slightly over the years from where we’ve done, but Len, why don’t you answer this from your perspective as what you currently recommend and maybe some of the past thoughts on that too? Because I think a lot of people have learned something in the past and then just go right back to what they were doing 10 years ago, without thinking about some new stuff. So what’s your current thought process on this?

Lenny Macrina: Without knowing what excessive hyperextension means in the question, I’m going to assume it’s that excessive like 10, 15 degrees of hyperextension, which is a lot for some people. But hyperextension is normal. If you measure people’s knees, they’re going to probably have four to six degrees easily of hyperextension.

Lenny Macrina: So the excessive person, 10 to 15 degrees, I would say maybe 10, 15, 20 years ago, we would say, “Maybe that’s why you tore your ACL. Let’s just get to zero and you’ll be fine.” Then we got some research that had come out that showed that those people, longterm, don’t do as well. So they have anterior knee pain. They may get some arthritis in the front of their knee, like the patellofemoral joint. They just never get back to their sport, because they always have irritation in the knee. So a couple of studies that I always go back to by Don Shelbourne out of Indianapolis, showed that the ligament has no extra laxity on it if you gain hyperextension back, meaning, similar to the other side to that person and their function improves, they feel better about their knee and people report that all the time.

Lenny Macrina: So for me, my goal in PT is to get hyperextension immediately. So again, depending on the person, if they are really loose-jointed, I’m not going to go at it as fast as somebody who only has three or four degrees and they are known to be somewhat tight, that’s just their persona. So for somebody who’s really loose-jointed, like the question asked, I’d probably say, get maybe half of it, something like that. If they had 10 to 15 degrees, I’d probably get five to seven degrees relatively quickly. I’m going to try to crank on their knee, but I want the patient to comfortably get it and feel comfortable getting it at home. Then the rest of it usually comes with just functional activities, because they have the underlying tissue laxity.

Lenny Macrina: There are some studies out there that show people who have hypermobile tissue have more elastin than collagen in their makeup. So they are going to get their motion back easier than somebody who doesn’t. But we don’t know that, we aren’t going to biopsy everybody’s legs, or perhaps everybody’s tissue, but I think you know pretty quickly by some kind of Beighton score or something like that and just getting information that will help guide how quickly you want to progress some people.

Lenny Macrina: But to answer the question, symmetry is important. Numerous studies have shown that it’s important for functional outcomes and won’t put stress on the ligament. That’s my goal, is pretty quickly try to get most of the motion back, but let the rest come back through function.

Mike Reinold: Going historically through that, I think this speaks to both our experience, but I think this is the general experience too. At first, I agree, we were definitely like, “Let’s get it all back. Let’s get hyperextension back right away.” Then I think we evolved a little bit like, “Let’s try to keep them at neutral.” A lot of people said, “Let’s keep it neutral. It’s going to put too much stress.” Then we’ve evolved to be a little bit more individualized, but tend to lean on restoring, but not forcing maybe. So let’s go through a couple of specifics and then anyone jump in, based on opinion.

Mike Reinold: Somebody on the contrel leg has zero to five degrees hyperextension, how much do you get back and how fast? Len, you want to start? And then if anybody disagrees or agrees.

Lenny Macrina: So they have five degrees of hyperextension, is that what you said?
Mike Reinold: Zero to five degrees. Somebody in that zone on the contralateral side, are you getting it all back and how fast?

Lenny Macrina: I’m going to probably get them to at least zero, at least… We measure, we’re probably going to have three to five degrees of error, but I’m going to get it back somewhat quickly, zero to twoish, I want to see a little hyperextension when they come in. I’m not going to try to get them to five right away, but I want to see a little hyperextension those first couple of weeks and we keep it. Because if we don’t keep it, if they start coming in and they start lacking extension, you start worrying about a Cyclops lesion. So the people that… Oh sorry, go ahead.

Mike Reinold: I see. No, no, no, I was going to say, so they have five degrees on the other side, you get them to two forever? Or do you ever get them to five?

Lenny Macrina: No, I’m going to get them to five eventually, but I’m going to monitor it. Every time somebody comes in to see me after an ACL, I don’t care if they’re nine months out of surgery, that’s the first thing I look on at somebody is their extension. I want to measure their extension. So for them, I’m not going to get it immediately, but I’m going to get them to five degrees eventually. How quickly that comes back, I don’t know, we’ll see. We’ll monitor it. If they are kind of hovering it two and they’re stuck there at eight months out of surgery, well, yeah, hopefully I didn’t mess that up and I need to be more aggressive, but I think they’re eventually… I’m going to get them to five degrees by the time that they are doing functional activities and feeling good.

Mike Reinold: Anybody else?

Dan Pope: It was too beautiful. I don’t want to mess it up as heck.

Mike Reinold: I feel like somebody in the zero to five range, I’d be a little bit more prone to get them to five sooner, to be honest. Because I think what we’re trying to do is I’m trying to chunk people in terms of their hyperlaxity.

Lenny Macrina: Correct. So instead of getting…

Mike Reinold: I feel like you would too.

Lenny Macrina: Maybe I didn’t say well, but if that person has 10 to 15 degrees of hyperextension, I’m not going to push on them. I’m going to let that come naturally because that’s going to come. But that person who’s probably a little tighter and only has that zero to five, somewhere in that range, I’m going to get twoish, threeish, something like that. Then just let the rest kind of hopefully come. But I’m probably going to be a little more aggressive, probably do a little bit low load, long duration stretching with them, because I know that they are just not that tissue lax person.

Mike Reinold: If they’re two months out and they’re two degrees versus five degrees, I know that doesn’t sound like a lot, I’m doing low load, I’m working on that, I’m concerned about that. I’d feel like the zero to five, I’d be a little bit more prone to get them closer to five sooner than later. Not week one, but probably within the first month. Now somebody with 15, 20 degrees on the other side, what do we do? How does that change the equation?

Lenny Macrina: There’s big arguments out there. So I’m always, as you guys know, hovering in social media world and there’s some docs are like…

Mike Reinold: The blogosphere.

Lenny Macrina: The blogosphere on the interweb. I have conversations on Twitter and stuff like that with docs who are like, “No, if they have 10 to 15 degrees of hyperextension, you keep them at zero, I don’t want them to tear their ACL.”

Mike Reinold: Zero?

Lenny Macrina: Yeah, zero or barely getting get hyper extension.

Dave Tilley: What’s the percentage of that difference though, when you think, that’s a 20% difference?

Lenny Macrina: Can you imagine being that person who has a 15, 20 degree difference in their amount of motion in their knee compared to the other side and how differently that feels. But the doc is concerned structurally, right? The doctor is concerned with re-tearing that ligament, we’re concerned with function. It comes down to this, oftentimes, especially with rotator cuff repairs. We’re concerned with function, can the person go and do their life? The doctor’s concerned with re-tearing that rotator cuff. Same thing with the ACL thing. For me, if there’s somebody has 15 degrees, I’m going to get them seven degrees or so, seven or eight degrees, about half and then-

Mike Reinold: Not nine. Nine would be bad.

Lenny Macrina: Not nine.

Dave Tilley: Pull that ligament out, nine. Mm-mm (negative).

Lenny Macrina: Roughly half.

Mike Reinold: No, I like that.

Lenny Macrina: Usually the rest will come back. I’ll prop them up. I’m not going to put a 10 pound ankle weight on their knee. I don’t need to do that, but I’m going to prop them up and just let gravity push their knee straight and I’m going to monitor them. I’m going to maybe give him a little over pressure. If they’re feeling pain in the front of their knee when I start doing over pressure or if I start assessing them, that’s usually more indicative of a Cyclops lesion, than if they feel pressure in the back of their knee, that’s going to be more indicative of capsule and/or hamstring. So that’s another nice little test that you can do, is that over pressure test. If you start seeing somebody losing motion or they’re kind of plateauing or getting irritable in the anterior knee, look for a Cyclops lesion, because it’s in five to 10% of cases typically, but I think it’s underdiagnosed and it’s a reason why people don’t get their motion back.

Lenny Macrina: It’s a lot of what I see in my practice, because of a blog post and a video that I did, people are finding me from all over the place, because of missing Cyclops lesions and just assuming getting zero is good enough.

Mike Reinold: So think about it. If you have 15 degrees of hyperextension and you only get zero to five, which a lot of people would say, that person is not getting to their terminal knee extension, they’re not getting their full screw home mechanism. They’re probably have their quadriceps isometrically engaged all freaking day. They’re all just like walking around. I can’t wait to see that transcribed below, all freaking day too, by the way.

Mike Reinold: Can I say, don’t transcribe those last two sentences, before this sentence, now three sentence…. I don’t know what to do, anyway. Think about it, if you’re used to having a hyperextension and you don’t, you feel like that thing is bent 90 degrees. It’s going to be a functional thing. We tend to see people with hyperextension that don’t get their extension back, have a really hard time getting their quad back. They’re going to have a ton of problems down the road with that. So it’s something to keep in mind. I guess just to summarize, I guess I would say again, that zero to five range, I feel like where you could argue, they’re not super lax, that’s the person that’s coming in, maybe we’re putting a little ankle weight over their distal thigh to give some over pressure into the extension, let them get that motion over time.

Mike Reinold: But somebody that’s 15 degrees, that’s somebody we get halfway and you just prop them up with a heel wedge and probably gravity’s enough to give them a little bit of an over stretching, we don’t have to be as aggressive with that. But I think the general concept is this, there is no one answer. There’s really no one answer to anything. It depends on the person, the tissue type in their amount of motion on their other side. So I guess the answer as always, it depends. But I think, if you think strategies like this, I think that’s a good way of doing it.

Mike Reinold: I will say that if you’re on either end of, let’s just jam it into hyperextension as far as we can, that could have some bad things. But I would say, you probably are more likely to have bad things if you’re on the other end and you let them get tight. So makes sense?

Lenny Macrina: Yeah.

Mike Reinold: Awesome. Good episode. Thanks Len. Always good to hear. Len’s the guy for these types of questions. I didn’t think that was a good rant. I mean, that was education, nothing to rant about. Should we ask about meniscal repairs and we have in the ’90s…

Lenny Macrina: Why are we stuck in the ’90s?

Dave Tilley: What about prone hangs? What about prone hangs?

Mike Reinold: How about prone hangs, yeah.

Lenny Macrina: That’s another episode

Mike Reinold: No, no. Great question, Lynn. Thanks so much. If you have a question like that, there’s a website,, click on the podcast link and you can fill out that form. Keep asking away. Head to iTunes, Spotify, rate, review, subscribe, whatever you guys do on podcasts things and we will continue. We’ll see you on the next episode. Thank you.

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