You’ve in all probability heard us discuss how stopping a lack of knee extension vary of movement is necessary after ACL reconstruction, proper?
Effectively, what about flexion? It occurs.
Take a look at this week’s podcast to be taught extra about how we forestall and deal with a lack of knee flexion.
To view extra episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 250: Lack of Flexion Vary of Movement after ACL Reconstruction
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Present Notes
Transcript
Mike Reinold:
And Max asks, “Hello, I’m a very long time listener, first time asker.” I like that. That’s humorous. “We’ve seen a rise in ACL reconstructions in highschool age athletes. I’ve two proper now which are quad tendon repairs, each are volleyball gamers. They’re between eight and 12 weeks out, however appear to be getting caught with knee flexion vary of movement,” flexion, attention-grabbing. We’ll discuss that. “I used to be questioning in case you have any recommendation or ideas on progressing knee vary of movement that appears to have plateaued. And what are your ideas on manipulation underneath anesthesia on this?”
Mike Reinold:
So let’s see, all proper. So to summarize rapidly for Max right here, lot extra ACLs in his clinic, occurs to have some quad tendons now. So possibly one in all his native physicians is beginning to use quad tendon repairs just a little bit extra or reconstructions just a little bit extra, which is ok. Possibly Lenny can chat briefly on if he thinks the quad tendon has something to do with that. However actually I feel what the large difficulty is right here is we’re getting eight to 12 weeks out and we appear to be getting caught in knee flexion vary of movement. So I don’t know when, Len, why don’t we begin with that. Do you assume this has something to do with the truth that it’s a quad tendon? Do you discover that you’ve a tougher time getting knee flexion with quad tendon repairs?
Lenny Macrina:
No. No, positively, no. I’m confused. In order that’s when possibly it’s a surgical method factor. Possibly it was tightening of the graft. That might be in all probability extra extension, however no, I haven’t had [crosstalk 00:03:43].
Mike Reinold:
You would lose flexion if-
Lenny Macrina:
I suppose it might. Yeah, you possibly can.
Mike Reinold:
If the tunnel placement or the graft tensioning is just a little off, that may very well be …
Lenny Macrina:
Yeah. What I’ve seen is lack of extension as a result of the quad tendon graft will get too huge. It’s an enormous graft. So it takes up that small, notch house within the knee. And I’ve seen docs need to go in and do a notchplasty to release that graft that’s pinching, however that was as a result of they had been dropping extension and there was no cyclops lesion current. So possibly it’s affecting their flexion. Medical doctors don’t appear to love to do notchplasties, however me rising up as a PT in Birmingham, they did notchplasties on everyone and thought it was useful.
Lenny Macrina:
So once you’re speaking a notchplasty, you’re speaking about taking out the bone that’s on the intercondylar notch of the femur to create more room for the graft to go in at that angle. So medical doctors don’t actually try this, no less than up right here in Boston. So I’ve seen a few situations the place you might have this huge voluminous, is that the phrase, quad tendon, which is a large graft in comparison with a hamstring or patella tendon. And it takes up an excessive amount of house, and now you begin getting just a little pinching of that graft and also you begin dropping movement. In order that may very well be that. Possibly in the event that they do do a scope, then they might discover that’s what’s occurring in there.
Lenny Macrina:
However to get the flexion again, it’s simply going to be repetitive bouts of flexion. So gentle tissue to the quad, gentle tissue to the hamstrings, passive movement. I put a video out on YouTube about attempting to work on inclined quad flexibility with placing your hand form of at the back of their knee and giving just a little anterior tibial drive to create, mainly placing the tibia in a distinct place and be capable of get a inclined flexion stretch that means of their quads. However with out realizing the precise numbers, if they’ve 120 levels, I wouldn’t be fearful. If they’ve 90 levels of flexion, yeah, then I’d be fearful. And also you begin speaking about possibly, I wouldn’t say a manip, however possibly manlike a debridement.
Mike Reinold:
Yeah, And that’s a part of what Max requested in his query right here too.
Lenny Macrina:
Proper.
Mike Reinold:
So let’s harp on the quad tendon then simply actual fast for a second. So is there something simply with the quad tendon clearly being a part of the extensor mechanism, is there something that would grow to be, we talked loads concerning the graft inside the notch. What about from the donor web site, from the quad tendon? Anyone have any expertise with that?
Lenny Macrina:
Once more, I haven’t seen something. I suppose it might as a result of it’s an extensor and it’ll restrict flexion if it will get scarred down, however I haven’t seen, me personally in my instances, if that’s been a problem. As a result of I work on scar tissue mobility. I’m engaged on gentle tissue mobility. I’m engaged on patellar mobility. And I’m comparatively aggressive with my movement early on so I don’t need it to be a problem down the street. I do know the place the trail might go and I keep away from it.
Mike Reinold:
Proper, that is smart. So I might say from our expertise then, Max, and anybody can soar in on this. We’ll form of shift gears on the query right here, however I’m not essentially certain that the quad tendon has something to do with it, however there’s an opportunity. It’s a thicker tendon, proper? There’s an opportunity. For those who’re beginning to discover that possibly there’s a sample, proper? Possibly it’s like one doctor that’s having a few of these lack of vary of movement points, that’s a sample, proper? That may very well be it. Is it solely along with your quad tendon grafts with that doctor? That’s a sample, proper? And also you form of begin trying into this.
Mike Reinold:
These may be some good conversations to have with the doctor in a non-confrontational means, proper? You don’t need to say like, hey, all of your sufferers stink, proper? No, simply be like, we appear to be scuffling with knee flexion vary of movement. Is there something method clever that we have to know of? Possibly it’s essential make an adjustment with these individuals that you just need to go just a little bit sooner with knee flexion vary of movement for them, proper, as a result of you recognize that they’re liable to get tight with this doctor, with this process, for instance. Fascinating. So I feel we’ll begin off by first simply form of nailing that and saying, I don’t know if there’s essentially one thing that’s inherently liable to dropping that vary of movement.
Mike Reinold:
After we’ve gotten that off the plate, now, let’s assist Max out just a little bit. So anyone else need to soar in now, what do you advocate Max do now, proper? He’s acquired individuals which are two, three months out which are dropping movement. What do you advocate Max do now? After which Lenny form of alluded to it, however how will we decrease this from occurring sooner or later? Dave?
Dave Tilley:
Yeah, I used to be going to say a mistake I made as a youthful clinician was form of pondering that no matter occurred two occasions per week for half-hour was going to counterbalance the opposite 40 to 50 hours they’re awake attempting to work on their knee movement after they’re at house. So I feel I’ve realized this loads from you guys is my previous self I might go just a little bit extra aggressive within the clinic, assume we acquired to get movement, we acquired to get movement, after which they wouldn’t actually be in depth sufficient at their house program. And so I feel generally backing off on how arduous you’re going within the clinic, after which simply constantly making use of lots of movement all through the day is means higher.
Dave Tilley:
So we’ll inform individuals like 10 knee bends an hour, proper, for each hour that you could presumably do it. For those who’re sitting at college. For those who’re sitting at house. For those who’re simply propped up watching TV. I feel that’s in all probability going to be a greater consequence. And I feel the analysis on stretching and what vary of movement adjustments have for the knee or any joint on the whole are in all probability going to be extra snug and tolerable for that individual than blasting on their knee and attempting to actually bend it like loopy within the clinic. Then depart with an indignant knee, after which now don’t need to do movement at house or the subsequent day as a result of they’re sore. In order that’s simply my two cents.
Mike Reinold:
Yeah, that’s level. I like that. Mike, how about you?
Mike Scaduto:
Yeah, I might say from an within the clinic perspective, at eight to 12 weeks out, I’d positively nonetheless be swelling and actually engaged on swelling administration. If the knee is swollen, it’s simply going to get just a little bit stiffer. After which positively patellar mobility nonetheless. If they’ve a scarcity within the superior inferior glide of the patellar that would have an effect on their flexion vary of movement. So these are two staple items I’d ensure that we’re positively nailing. After which like Lenny stated, and I feel Dave stated as effectively, simply constant bouts of seated vary of movement off the sting of the desk, passive vary. And simply doing that for a fairly lengthy length within the clinic, not an extended length stretch, however doing lots of repetitions of flexion vary of movement within the clinic would form of be my technique. Be sure we’re nailing all these staple items early on.
Mike Reinold:
Proper. Good pivot, proper? You understand, look, it’s 12 weeks out. There’s tons that it’s essential do with this individual, however possibly their main factor that they want your arms for is to get that vary of movement again. So possibly focus just a little bit extra time on that. It’s attention-grabbing, you talked about patellar mobilizations, which I believed was fairly good too. With a quad tendon restore, possibly utilizing the quad tendon, you didn’t focus fairly sufficient on patellar mobility. That may be a part of it. Yeah, I like that. Dan Pope, what do you assume?
Dan Pope:
Certain. I’m simply going so as to add to what Mike stated. I feel swelling may be actually huge. In case you have lots of swelling I feel that’s huge for lowering flexion vary of movement. Particularly for lots of oldsters you’re battling lots of swelling additional alongside the rehab course of, I feel an enormous motive why individuals have lots of swelling is possibly an excessive amount of train or possibly the person is doing an excessive amount of strolling on their very own. They’re doing an excessive amount of exercise on one given day. So I discover myself doing lots of counseling for people to attempt to break up their exercise throughout per week, carrying a pedometer, be sure that not doing an excessive amount of strolling on any particular day. And if I’ve to have a look at a few of my workout routines as a result of they’re creating an excessive amount of swelling, I would pull again on these to be sure you’re getting the vary of movement and progress effectively over time.
Mike Reinold:
I prefer it. That’s good. All proper. Dave, you bought just a little bit extra so as to add.
Dave Tilley:
Another factor is I feel oftentimes if the train dosages, like Dan’s saying, generally loaded actions can actually reinforce what they’ve or what they’re gaining. So discovering workout routines that don’t damage, that aren’t painful, like partial arch field squats or eccentric lowers, I feel generally the precise eccentric loading is definitely actually necessary to transform a few of that tissue and make it stick comfortably.
Mike Reinold:
I like that. What’s up Mike?
Lenny Macrina:
Oh, go forward Mike.
Mike Scaduto:
Yeah, effectively, I simply form of had a query. I do know we lined this matter a very long time in the past, however somebody requested about doing joint mobes on the knee publish ACL surgical procedure. Do you assume this is able to be a case the place we’d do any joint mobes on this individual? Tibiofemoral or not patellofemoral?
Mike Reinold:
I suppose I’d throw it out to the group too, as a secondary a part of that. Do we predict that the joint is what’s limiting his vary of movement?
Mike Scaduto:
You actually have to concentrate to end-feel and all that, amount and high quality of movement.
Mike Reinold:
I don’t know. I’ve personally by no means achieved joint mobes on a post-op ACL aside from patella. We at all times get our vary of movement again. I don’t know, does anyone assume that’s wanted.
Lenny Macrina:
Yeah, I agree. I see lots of people doing inside rotation glides and really attempting to get the screw house mechanism for extension and all that. However I haven’t achieved it and I by no means actually have a problem, however I don’t understand how a lot it’s doing. And I don’t know if it’s a joint mobility factor. It may very well be at eight, 12 weeks out the joint capitals are inclined to get just a little tight. It may very well be, however I nonetheless assume the low hanging fruit is all the opposite stuff. I’d even be curious if this individual, which we don’t know within the particulars, we don’t even understand how tight they’re, in the event that they’re actually tight, however did they’ve a meniscal restore the place the physician restricted them to 90 levels of flexion for 4 or six weeks, which appears to be the development. That’s going to actually put any person behind too since you go 90 levels. They get that at like 10 days post-op on the most. And now you’re sitting there ready for time to go by to have the ability to get the remainder of that movement again, they usually do get stiff. So I’m wondering if there’s a protocol difficulty as effectively, moreover a surgical or another form of difficulty that’s lending to those individuals which are getting tight.
Mike Reinold:
That is smart to, once more, one other factor about is there a sample growing right here in individuals which are being restricted with their vary of movement. All proper. Final a part of Max’s query although is what are our ideas on a manipulation for this individual? I don’t know. Who’s handled that? Anyone need to soar in on that?
Lenny Macrina:
I might say possibly a scope. For those who’re nonetheless at 12 weeks they usually’re struggling, they’re younger individuals, they need to get their movement again over time. However possibly a scope if they’ve, clearly, a nasty end-feel they usually’re nonetheless struggling, and also you’re not making any features. Possibly a scope to go in there and debride it out and see if there’s a notch impingement by the graft or one thing like that they usually need to do a notchplasty. That might be a surgical choice. Not in opposition to it, I’ve seen it. I’ve had some individuals in my profession have to do this, but it surely’s positively few and much between.
Mike Reinold:
Would you reasonably scope to scrub out just a little bit or would you attempt only a manipulation with a eight, 10, 12 week ACL reconstruction?
Lenny Macrina:
Yeah, I feel from what I’ve seen, it’s usually a scope. I feel it’s going to be physician desire.
Mike Reinold:
Yeah, I really feel like most physicians would in all probability reasonably scope that versus a complete knee substitute at 12 weeks or one thing. I really feel just like the doctor’s in all probability just a little bit extra snug with being aggressive with that complete knee substitute at that time.
Lenny Macrina:
Sure.
Mike Reinold:
Superior. All proper. So Max, I feel in abstract, search for some patterns right here. You might need some patterns. And these could also be larger issues than us, proper? This may increasingly need to perform a little bit with the doctor preferences and strategies, and protocols, and stuff like that. So clearly preserve that in thoughts. However in your finish, clearly take a few of the suggestions that everyone form of gave you when it comes to methods to ensure that we’re restoring movement early and ensure we’re doing with these sufferers each at house and within the clinic. And hopefully I feel now sooner or later, which I feel this can be a good possibly studying expertise for you, sooner or later you’re like, all proper, these sufferers are liable to lose knee flexion. What can I do to be just a little bit extra proactive to forestall that?
Mike Reinold:
I feel these are the issues that we’ve all been by way of, proper, and have modified the way in which we apply as a result of we don’t need this to occur and we’ve seen it occur. So it adjustments you. Nice stuff, Max. I admire it. In case you have a query like that, head to MikeReinold.com, click on on that podcast hyperlink and you’ll want to head to iTunes and Spotify, and fee and assessment and subscribe to our podcast so we will see you on the subsequent episode. Thanks a lot.
