Latest / The ACL Athlete Podcast / 297 | Audit Your Knee Extension: A Simple Assessment for ACL Rehab

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297 | Audit Your Knee Extension: A Simple Assessment for ACL Rehab · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:01
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete podcast.
• 1:08
  SPEAKER_00: So let me start with something that we see quite often.
• 1:12
  SPEAKER_00: An athlete comes to us and they've been told that their knee extension is fine.
• 1:19
  SPEAKER_00: Or that maybe it'll come back with time or to just keep working on it.
• 1:24
  SPEAKER_00: Especially if they are in these early windows, let's say less than three months post-op, they are told to keep working on it, it'll come back with time.
• 1:34
  SPEAKER_00: Or maybe it's normal, right?
• 1:36
  SPEAKER_00: Especially if someone has achieved maybe just a zero degree extension.
• 1:41
  SPEAKER_00: And in particular, I'm thinking about one case that has come up recently where they were further out, much further out.
• 1:49
  SPEAKER_00: They had a scan earlier on because the knee wasn't acting right.
• 1:53
  SPEAKER_00: And we're talking about early months of post-op.
• 1:56
  SPEAKER_00: And there was something that came up on there, but it was essentially considered normal.
• 2:02
  SPEAKER_00: And then they started to just kind of feel like they were the crazy ones after you know time goes on and the knee just wasn't feeling normal, right?
• 2:11
  SPEAKER_00: Like they weren't getting the extension back, or it was just kind of feeling grumpy all the time, and it wasn't really progressing like they were hoping, especially from a range of motion standpoint.
• 2:21
  SPEAKER_00: And nobody's necessarily finding out this issue.
• 2:24
  SPEAKER_00: And so then, you know, this person comes to us, shares these findings, and then we assess and see certain things.
• 2:30
  SPEAKER_00: We put some things in play to see is this more of they aren't doing the right things, or is this more so of a biological thing?
• 2:38
  SPEAKER_00: And that's one of the things we're really trying to determine, especially for someone who's coming in later in the process where they have been doing some rehab, but they're dealing with issues.
• 2:47
  SPEAKER_00: Is this more of the body's internal biology having an issue that we're up against, or is it truly just they just weren't given the right rehab approach to be able to progress things forward?
• 2:59
  SPEAKER_00: And so we're looking at this and assessing, and when we look closer, there's something in the joint that was getting in the way this whole time.
• 3:08
  SPEAKER_00: And I want to be really clear here that this is not about blaming anyone, but this is what to look for because it gets missed a lot.
• 3:19
  SPEAKER_00: I mean a lot, y'all.
• 3:20
  SPEAKER_00: A lot.
• 3:21
  SPEAKER_00: And I think in this episode, the goal is to be able to audit your own knee extension, what the results mean, and what to do next.
• 3:30
  SPEAKER_00: It is one of the most common issues in ACL rehab that come up early.
• 3:36
  SPEAKER_00: And I would say majority of the time, it is something that the can get kicked down the road.
• 3:44
  SPEAKER_00: And don't get me wrong, there are situations where we need to just give it some time, and some knees are tricky, but this kind of comes back to the pattern recognition, working with someone who knows this process, so that way there can be objective metrics that are connected to this.
• 4:01
  SPEAKER_00: You are also being able to have this tracked within weeks to just kind of see how the knee is progressing, and is there any shift in the positive for it?
• 4:12
  SPEAKER_00: And especially if you're doing all the things you can control, you've dialed things in and things are not improving, then this is something that needs to be looked at further.
• 4:22
  SPEAKER_00: And because of just the way that the procedure goes, that when you're in those first three months, four months, you might have a follow-up visit at month three with your surgeon.
• 4:35
  SPEAKER_00: Again, they are typically looking at you and evaluating you in those moments at maybe you know, five minutes, ten minutes max, they're looking at the knee.
• 4:46
  SPEAKER_00: It's more of a conversation, very brief, and then you carry on, keep rehabbing, right?
• 4:52
  SPEAKER_00: Or it'll come with time.
• 4:53
  SPEAKER_00: Unless there is a very big red flag apparent, it's typically let's just keep working on it.
• 4:59
  SPEAKER_00: And again, these problems don't necessarily always arise immediately post-op.
• 5:04
  SPEAKER_00: They could also develop at month six or month nine or later in the process.
• 5:09
  SPEAKER_00: But it's important to make sure that this is always being audited, always being tested to make sure that it is there, it is maintained, and it is never lost.
• 5:21
  SPEAKER_00: And that is one of the things that is really clear here.
• 5:24
  SPEAKER_00: And what was so sad about this situation is that it could have been caught very early.
• 5:30
  SPEAKER_00: And this person could have had a much different trajectory than being 15 months post-op and having the same issue still there that could have been caught earlier on imaging.
• 5:41
  SPEAKER_00: And so today the goal is to talk through extension in a little bit more detail and an auditing process of yourself so that way any of you who are dealing with extension, you're able to look at this yourself, maybe talk with your PT, talk with your surgeon, and then be able to also recognize some of these patterns.
• 6:00
  SPEAKER_00: And whether you're kind of in this category of like keep working on it, maybe, or maybe you're someone that needs to look into it a little bit further, right?
• 6:08
  SPEAKER_00: What's the next step just to be prepared versus waiting another three months and you're still stuck in the same place?
• 6:15
  SPEAKER_00: And this is something, again, like as I've shared in previous episodes, I get that we have a bias selection of people who are having complications in cases because they're not getting the help that they need.
• 6:27
  SPEAKER_00: So we're probably seeing more of the harder.
• 6:29
  SPEAKER_00: Yeah, we might see more cyclops, more scar tissues, and things like that.
• 6:33
  SPEAKER_00: But I think what is referenced in the literature, or maybe what is also mentioned in surgeons' offices, is not really representing the whole.
• 6:44
  SPEAKER_00: There's way more of this stuff that is happening as a kind of secondary byproduct of this ACL surgical process.
• 6:53
  SPEAKER_00: And so the important thing is to be able to be in front of it, so then that way you can get the help that you need.
• 6:59
  SPEAKER_00: So then that way, if there needs to be another cleanup procedure, that is done versus you know getting a year into this, and this could have been addressed at month four.
• 7:10
  SPEAKER_00: So if you are post-injury, post op, I would argue knee extension is the number one priority in this process.
• 7:18
  SPEAKER_00: It's the thing that is high up for us.
• 7:21
  SPEAKER_00: It's a part of the quiet knee, but it supersedes knee flexion and it coincides with getting your quads active.
• 7:29
  SPEAKER_00: So it's gonna be the number one priority for us.
• 7:34
  SPEAKER_00: And here's why: the further out you get from this injury, or especially from the surgery, the more that the joint settles into where it wants to be.
• 7:46
  SPEAKER_00: It's much easier to be able to get that extension back because that surgeon, whenever you have the surgery, they go through cycles of flexion and extension.
• 7:57
  SPEAKER_00: So they're checking to make sure you have full terminal knee extension.
• 8:01
  SPEAKER_00: They're also making sure that you have full flexion, right?
• 8:05
  SPEAKER_00: So that joint has access to that as you get out of the surgery.
• 8:09
  SPEAKER_00: Of course, then there's swelling, then there's just the inflammatory process that takes place, muscle guarding.
• 8:16
  SPEAKER_00: And so that is some of the things that, yeah, can kind of inhibit being able to access that immediately.
• 8:22
  SPEAKER_00: And so that is something that we have.
• 8:24
  SPEAKER_00: But the further away we get from surgery, the further that these kind of fibers start to heal, and everything around the joint starts to create its new normal.
• 8:33
  SPEAKER_00: And so if someone were to go six months with 10 degrees of flexion or extension, if you will, they're gonna start to normalize into that.
• 8:41
  SPEAKER_00: And it's gonna be way harder for that person to get back to zero or hyperextension versus the person who is in the earlier weeks of their post-op period because the joint is not fully settled down yet and healed, and so the tissue is going to continue to adapt to whatever positions you leave it in.
• 9:00
  SPEAKER_00: So we want to restore that as early as possible.
• 9:04
  SPEAKER_00: And I'm going to say this one twice because it really does matter.
• 9:09
  SPEAKER_00: Knee extension does not get better with time, it does not get better with time.
• 9:16
  SPEAKER_00: You have to intentionally work on it, otherwise, it keeps that slight bend, and you can just kind of settle in there, and it might just be a slight bit of flexion as you walk or a slight little bend.
• 9:32
  SPEAKER_00: And those of you who have a little bit of knee extension that is not fully there, you know what I'm talking about.
• 9:38
  SPEAKER_00: And we have athletes who are very familiar with this, that we are helping to work through these things as they come in, and it's something that I think is really important to just understand that a slightly bent knee is not okay, and also just zero, in our opinion, is not okay unless that is your norm on your uninvolved side.
• 9:59
  SPEAKER_00: In our experience, when you don't get that knee extension back, and also in the research, there's a trickle-down effect.
• 10:05
  SPEAKER_00: More scar tissue can build into the knee, and that could be around the joint.
• 10:09
  SPEAKER_00: It could also form as a cyclops lesion, which we have data to support.
• 10:13
  SPEAKER_00: If we don't regain extension, that cyclops lesions are more likely.
• 10:18
  SPEAKER_00: It can turn into a limp that you know just inevitably will transfer over because you don't have extension and you need extension to be able to go through a gait cycle.
• 10:27
  SPEAKER_00: It will impact the way your quad will fire and the way that it should.
• 10:31
  SPEAKER_00: You know, if you try to extend or straighten out your elbow, you have hyperextension in your elbow.
• 10:36
  SPEAKER_00: So if you can only get to zero, you're gonna actually be shy of being able to fully activate that tricep just like you want to.
• 10:44
  SPEAKER_00: The quad works the exact same way.
• 10:46
  SPEAKER_00: And the other thing that's so important here is that osteoarthritis is also connected to not regaining extension.
• 10:55
  SPEAKER_00: Shelburne has done some studies on this.
• 10:58
  SPEAKER_00: And the thing is that it changes the way that the joint interacts with the patella, the femur, and just all of the mechanics of the joint and where stress is being put when you go through a gait cycle, when you jump, when you do all kinds of things on loading the knee.
• 11:12
  SPEAKER_00: If you don't have full knee extension, that is going to impact where load is being placed on the cartilage and all around the knee joint.
• 11:20
  SPEAKER_00: So that is just a general domino effect that can happen when extension is not fully restored.
• 11:26
  SPEAKER_00: And this is something that I have talked about in earlier episodes.
• 11:29
  SPEAKER_00: So go back to listen to those.
• 11:31
  SPEAKER_00: I've done deep dives on knee extension.
• 11:33
  SPEAKER_00: And a lot of people hear one of two things, which is very common, that zero is fine.
• 11:40
  SPEAKER_00: They'll either hear it from their physical therapist or their surgeon, and they'll say, Oh, zero is fine.
• 11:45
  SPEAKER_00: We intentionally did not want you to get into hyperextension.
• 11:48
  SPEAKER_00: And then they'll also hear maybe that they spend two to four weeks working on it or maybe a little bit more time.
• 11:56
  SPEAKER_00: And then they move forward because the protocol or the timeline, you know, it just kind of says it's time, right?
• 12:02
  SPEAKER_00: You've been working on the quad sets, straight leg raises, right?
• 12:06
  SPEAKER_00: Which are things that are typical in most initial post op stuff that people do.
• 12:11
  SPEAKER_00: But with that said, like over time, it's just, you know, we move on to other things.
• 12:16
  SPEAKER_00: But good enough does not work in extension.
• 12:19
  SPEAKER_00: It does not.
• 12:20
  SPEAKER_00: Good enough is what's the saying?
• 12:22
  SPEAKER_00: Good enough only works in horseshoes and hand grenades, right?
• 12:27
  SPEAKER_00: This is something that it doesn't work.
• 12:30
  SPEAKER_00: We need exactly what we need here because there is a foundational effect from this.
• 12:36
  SPEAKER_00: You want to build this in, and then there's a domino effect of what that impacts from a re-injury standpoint or performance standpoint, and then all the other things that I had shared earlier about what this could lead to.
• 12:48
  SPEAKER_00: Zero is not the goal.
• 12:49
  SPEAKER_00: I don't care who you talk to, zero is not what normal values are.
• 12:54
  SPEAKER_00: If you look at most people's knees, they hyperextend.
• 12:59
  SPEAKER_00: It could be minus two, it could be minus five, it could be minus seven, it could be minus ten.
• 13:05
  SPEAKER_00: And for yeah, the hypermobile people, people who have excessive extension, they could get into the minus 15, minus 20.
• 13:13
  SPEAKER_00: We've seen it.
• 13:14
  SPEAKER_00: The thing is that it's more rare.
• 13:17
  SPEAKER_00: Like most people are not dealing with excessive hyperextension.
• 13:21
  SPEAKER_00: But the thing is, your gold standard is your uninvolved side.
• 13:25
  SPEAKER_00: Again, with the caveat of the hyperextension that has hypermobility, minus 15, minus 20.
• 13:33
  SPEAKER_00: But for 90% of cases, most of you are not gonna have to really deal with that.
• 13:38
  SPEAKER_00: And the uninvolved side is going to be your gold standard and what you compare to.
• 13:42
  SPEAKER_00: You're not comparing yourself to some averages or whoever else is in the clinic, Bertha or Ronald, whoever it might be, you're matching it to your own other knee.
• 13:53
  SPEAKER_00: And yeah, if you have also had an injury on that side, and let's say extension was not regained, then yeah, we're gonna try and get you into some hyperextension.
• 14:03
  SPEAKER_00: And that is also gonna be looked at in terms of making sure functionally you're not limited and you're able to do all the things you need to from a quad activation, walking, and all the other like progressions from there to be able to make sure you have back what you need.
• 14:18
  SPEAKER_00: With the hypermobile athletes, I've talked about this before, but we might be only getting back minus five, minus 10 of that hypermobility or the extension versus that full 15, 20 degrees of hyperextension.
• 14:31
  SPEAKER_00: And that's something that, yeah, there is a certain threshold, but again, it doesn't apply to most people.
• 14:36
  SPEAKER_00: And the one thing that I want to bring into this is that I was digging into my textbook and I was also just doing a further lit review of what normative values are in the knee extension world.
• 14:49
  SPEAKER_00: And this is the thing that I was like, I remember it being into hyperextension and it being into five to tens.
• 14:57
  SPEAKER_00: And so I'm gonna read this to you directly from my functional anatomy book, and it's an awesome book: Kinesiology of the Musculoskeletal System, Foundations for Rehabilitation, Donald Newman, a very, very foundational book in the process of understanding joint anatomy, functional anatomy, biomechanics, and all the things.
• 15:20
  SPEAKER_00: I geeked out in this book.
• 15:22
  SPEAKER_00: All right, here's what it says, and I'm reading this as I'm holding it in front of me.
• 15:26
  SPEAKER_00: Knee flexion and extension.
• 15:28
  SPEAKER_00: Flexion and extension at the knee occur about a medial lateral axis of rotation.
• 15:35
  SPEAKER_00: Range of motion varies with age and gender, but in general, the healthy knee moves from 130 to 150 degrees of flexion to about five to ten degrees beyond zero degree in the straight position, meaning it can go from minus 10 to minus 5, and it can also go from 130 to 150 degrees of flexion.
• 16:01
  SPEAKER_00: So that is something that is coming straight from this textbook.
• 16:05
  SPEAKER_00: And when you look across the research and when you look across normative values and resources that we use, that it typically says, yes, there's zero included, but then five to ten degrees of hyperextension is normal.
• 16:19
  SPEAKER_00: Those are within normal limits.
• 16:21
  SPEAKER_00: And I've tested enough knees at this point that I promise you, majority of knees go into the negatives.
• 16:28
  SPEAKER_00: Any orthosurgeon you talk to who tests knees truly, there is some negative degrees.
• 16:34
  SPEAKER_00: And when you talk to PTs who are let's line up 100 PTs and let's see what they say.
• 16:41
  SPEAKER_00: Promise you that when you assess extension, there is going to be some hyperextension for majority of the people that we are assessing.
• 16:49
  SPEAKER_00: And so this is really important because zero is something that we have to see all the time that people are like, well, my PT said zero is fine, or my surgeon said zero is fine.
• 17:01
  SPEAKER_00: We don't want you in hyperextension.
• 17:02
  SPEAKER_00: And I disagree.
• 17:04
  SPEAKER_00: That is the thing that we need to get back because it is important to the architecture of the joint in the way that all these kind of dominoes really do influence the way that the knee is going to respond to stress and force and load, and we need to get that back.
• 17:20
  SPEAKER_00: And what I want to talk about next that's really important here is just how we're gonna assess this.
• 17:27
  SPEAKER_00: And I've talked about this before of auditing your flexion and extension, but today we're focused on extension.
• 17:34
  SPEAKER_00: This is the easiest self-audit there is, and it's how we assess extension remotely.
• 17:40
  SPEAKER_00: People ask me all the time, you know, even with remote, like how are we able to see this?
• 17:45
  SPEAKER_00: And technology is awesome.
• 17:47
  SPEAKER_00: We are able to really pull so much from the remote side and get so much detail.
• 17:52
  SPEAKER_00: And this is something with hundreds and hundreds of AC healers at this point.
• 17:56
  SPEAKER_00: We've never touched their knees, and we've been able to assess their range of motion, and we've been able to implement strategies to be able to regain their range of motion and assess appropriately.
• 18:06
  SPEAKER_00: So here's the setup for us to be able to look at their terminal extension side to side and see how it works.
• 18:14
  SPEAKER_00: And what does it look like?
• 18:16
  SPEAKER_00: You have a hardwood floor, a hard surface.
• 18:18
  SPEAKER_00: We do not want to be on carpet, not on a bed.
• 18:21
  SPEAKER_00: We want on something that is hard.
• 18:23
  SPEAKER_00: And you are gonna be bare feet, no socks, nothing underneath your knees.
• 18:28
  SPEAKER_00: Your legs are gonna be straight out, and you're gonna be sitting on your butt on the floor, and you know, you'll have your hands right next to you.
• 18:37
  SPEAKER_00: You could also be laying down as well, but you could easily just kind of sit on your butt, and then you're gonna have your feet straight out in front of you.
• 18:44
  SPEAKER_00: Step one is we're gonna look at the active test, which is really just gonna be a quad set.
• 18:50
  SPEAKER_00: And the detail here is important because a lot of times people will do this and they'll just kind of push into the ground and is actually activating their hamstrings.
• 18:58
  SPEAKER_00: Maybe some quads are getting active, but we need to make sure we do this correctly.
• 19:02
  SPEAKER_00: So when you start on the uninvolved side, you are going to do a quad set.
• 19:07
  SPEAKER_00: So the goal is to squeeze your quad, and what should happen is the gap underneath your knee is flattening down towards the ground and to the floor, and your heel lifts up off the ground, and you'll feel it getting lighter.
• 19:22
  SPEAKER_00: Both the heel and the back of the knee should not be in contact.
• 19:26
  SPEAKER_00: The back of the heel should be lifting as you flatten the knee down to the ground, and your heel lifts up off the ground.
• 19:33
  SPEAKER_00: That is the heel pop.
• 19:34
  SPEAKER_00: We want that heel to pop up off the ground, and it might be the ability to slip just some paper underneath the heel.
• 19:43
  SPEAKER_00: It might be a half inch or like a very thin book, or you know, if you're hypermobile, you might get some height there.
• 19:49
  SPEAKER_00: You might get an inch or two or more if you're super hypermobile and you can get up and get that heel pop going.
• 19:55
  SPEAKER_00: Everyone is different, but note it on your uninvolved side.
• 19:59
  SPEAKER_00: This is your standard here in terms of what we are aiming for.
• 20:03
  SPEAKER_00: Now do the same thing on the involved side.
• 20:06
  SPEAKER_00: Does your knee flatten to the ground?
• 20:08
  SPEAKER_00: Does your heel lift?
• 20:09
  SPEAKER_00: Can you see and feel your quad contract?
• 20:13
  SPEAKER_00: Step two is the passive test.
• 20:16
  SPEAKER_00: This one you're going to need a rigid strap or a belt or a towel, not a stretchy resistance band.
• 20:24
  SPEAKER_00: Do not do your knee extension work with a stretchy resistance band.
• 20:28
  SPEAKER_00: Do something that is rigid.
• 20:30
  SPEAKER_00: Hook it around your foot and use your hand to hold the top of your thigh just above your kneecap down to the floor.
• 20:35
  SPEAKER_00: So you're gonna kind of overpressure down.
• 20:38
  SPEAKER_00: The goal is to keep the back of the knee flat and pull the heel up with the strap.
• 20:43
  SPEAKER_00: Using your arm and you're not activating your quad whatsoever.
• 20:47
  SPEAKER_00: The passive test is no muscle activation.
• 20:51
  SPEAKER_00: The active test is you're using your quads to get into knee extension.
• 20:56
  SPEAKER_00: And the whole leg should not lift up with either of these tests.
• 21:01
  SPEAKER_00: You're flattening the back of the knee down into the floor and seeing how far the heel comes up with the quad relaxed.
• 21:09
  SPEAKER_00: And this is with that passive test.
• 21:11
  SPEAKER_00: Now you're gonna do it on your uninvolved side first and then do it on your involved side.
• 21:15
  SPEAKER_00: Now you have data.
• 21:17
  SPEAKER_00: You have assessed, you have assessed passive on both sides, you have assessed active on both sides.
• 21:23
  SPEAKER_00: And you're also needing to know how does it feel on each side?
• 21:27
  SPEAKER_00: Is there some sharpness, any dull, achy, something around the kneecap, something in the shin?
• 21:33
  SPEAKER_00: That all matters too.
• 21:34
  SPEAKER_00: So write it down as you do these four different ones.
• 21:38
  SPEAKER_00: You're doing the active on the uninvolved, you're doing the passive on the uninvolved, and then you're doing the active on the involved and the passive on the involved.
• 21:47
  SPEAKER_00: So four different quick assessments.
• 21:50
  SPEAKER_00: I would suggest recording a video.
• 21:51
  SPEAKER_00: You could do it from the side.
• 21:53
  SPEAKER_00: You could also do it from the bottom, where you can also see the bottom of your feet to assess.
• 22:00
  SPEAKER_00: That's the heel height side to side.
• 22:02
  SPEAKER_00: Now you have that data along with some notes with it.
• 22:06
  SPEAKER_00: And here's how you read the results the key rules.
• 22:10
  SPEAKER_00: If you can't get there passively, you cannot get there actively.
• 22:14
  SPEAKER_00: Passive is the door you have to go through first.
• 22:17
  SPEAKER_00: So think about your shoulder.
• 22:19
  SPEAKER_00: If someone lifts your arm for you, again, you're not doing it, with your muscles relaxed, and it gets stuck at let's say parallel to the ground.
• 22:27
  SPEAKER_00: So if you just hold, if they lift it just to your arm out in front of you, parallel to the ground, no amount of strengthening is going to get that arm overhead.
• 22:37
  SPEAKER_00: The joint won't let you get there.
• 22:39
  SPEAKER_00: So you have to get that passive range first before the active allows you to get there.
• 22:44
  SPEAKER_00: And that is just like a very basic principle of physical therapy and joint mechanics.
• 24:55
  SPEAKER_00: So here are your possible outcomes when you look at this.
• 24:58
  SPEAKER_00: Outcome number one, passive matches the other side, the active does not.
• 25:03
  SPEAKER_00: This is actually good news.
• 25:05
  SPEAKER_00: So we love to see this with our athletes.
• 25:08
  SPEAKER_00: It means the joint has access to the position.
• 25:11
  SPEAKER_00: You can get there.
• 25:12
  SPEAKER_00: And now it's more of like an active quad-related thing.
• 25:16
  SPEAKER_00: There could be some symptoms that are impacting that too from activating.
• 25:20
  SPEAKER_00: But we're working a lot on that terminal extension through activation and some techniques, quad sets with some assistance that we have using NMES or with a strap and different movements, and getting that muscle to recreate the position.
• 25:35
  SPEAKER_00: We can work with this.
• 25:37
  SPEAKER_00: Outcome number two: passive and active both fall short.
• 25:41
  SPEAKER_00: This is where we have to play detective.
• 25:44
  SPEAKER_00: Is it muscle guarding?
• 25:45
  SPEAKER_00: Is there swelling in the joint that's limiting it?
• 25:48
  SPEAKER_00: Is there something structural biologically, like a cyclops lesion, other scar tissue?
• 25:54
  SPEAKER_00: This one needs a closer look.
• 25:57
  SPEAKER_00: And it could take techniques to open up the passive.
• 26:00
  SPEAKER_00: Again, it doesn't mean it's automatically scar tissue, but it is something that we need to put into play certain techniques to get this thing to open up based on what we're seeing.
• 26:10
  SPEAKER_00: And if it doesn't, we may need some imaging, but you need someone experienced to be able to assess this very clearly.
• 26:19
  SPEAKER_00: And then outcome number three, both match the uninvolved side.
• 26:23
  SPEAKER_00: Great.
• 26:24
  SPEAKER_00: Now we check it functionally.
• 26:25
  SPEAKER_00: What about standing?
• 26:27
  SPEAKER_00: How does it look with doing terminal knee extension-based movements?
• 26:30
  SPEAKER_00: What about walking?
• 26:31
  SPEAKER_00: What about the knee that goes through extension through a gait cycle?
• 26:35
  SPEAKER_00: What about other positions that need terminal knee extension, like an acceleration-based position?
• 26:42
  SPEAKER_00: So we're looking at extension as an entire profile.
• 26:45
  SPEAKER_00: It's not just what does it look like on the ground or on a table.
• 26:49
  SPEAKER_00: It's also looking at it through a bunch of different positions to build an overall profile, not just one single number or position.
• 26:57
  SPEAKER_00: But you do have to have just isolated extension all by itself in order for it to be accessible in those other functional positions.
• 27:08
  SPEAKER_00: No one has terminal knee extension in standing, and then when you put them down and lay them down on a table and you assess them passively, and they don't have it.
• 27:16
  SPEAKER_00: You have to have that passive extension and then also the active components too to transfer over to the functional components.
• 27:24
  SPEAKER_00: And a few important things here to just note.
• 27:27
  SPEAKER_00: If your knee feels like it hits a hard block, like something is physically in the way instead of a stretch, don't keep forcing it.
• 27:36
  SPEAKER_00: Get an experience, clinician, or have your surgeon look at it, but just have someone look at it.
• 27:42
  SPEAKER_00: And again, with enough overpressure, you could probably get the knee to look like it has some hyperextension or can get there, but there can be enough force to make it feel that way in a moment, but you have to track it over a period of time of days to just see like, does it regress back and does it improve at all?
• 28:04
  SPEAKER_00: And this is something that we notice too is that when people walk into a surgical visit, for example, or even a PT visit, and there's a goal of like really trying to overpressure and convince ourselves there's more there, I can jam your knee into hyperextension and get a little bit more out of that.
• 28:22
  SPEAKER_00: Everyone kind of knows this feeling, but we have to track the data over time.
• 28:27
  SPEAKER_00: It's not just that one moment.
• 28:28
  SPEAKER_00: What does the data look like across days and weeks?
• 28:31
  SPEAKER_00: And has that improved at all?
• 28:34
  SPEAKER_00: And if it hasn't and it rebounds back, then we need to start talking about what's going on.
• 28:39
  SPEAKER_00: And if you lose suddenly that extension you used to have, or maybe the knee swells up or it feels warm, same thing.
• 28:48
  SPEAKER_00: We have to assess and see what's happening here.
• 28:50
  SPEAKER_00: And if you have calf pain, swelling, warmth after the surgery, we got to get that checked, right?
• 28:55
  SPEAKER_00: So those are important things to look out for.
• 28:58
  SPEAKER_00: I'll also say this do the audit yourself because it's helpful.
• 29:02
  SPEAKER_00: But I suggest doing it with someone who's experienced with this process because they can make more sense of this information.
• 29:09
  SPEAKER_00: Like this naturally creates a one, two, three-step process for me.
• 29:15
  SPEAKER_00: Whenever I hear passive matches the other side, active does not.
• 29:19
  SPEAKER_00: Passive and active both fall short versus both match the uninvolved side.
• 29:24
  SPEAKER_00: Like this automatically makes our brains go through a process to be able to understand, okay, this is what our action plan is going to look like.
• 29:32
  SPEAKER_00: And it's going to look very different across these different outcomes.
• 29:36
  SPEAKER_00: And so make sure you have someone who is experienced in ACL rehab, a physical therapist, to help get clarity on what it means and not just trying to troubleshoot it alone.
• 29:46
  SPEAKER_00: And so this is something that you can't necessarily always stretch your way out of or hope it comes with time, especially if that passive is not accessible.
• 29:57
  SPEAKER_00: That is where we need to really play detective and figure out is it more muscle-based?
• 30:02
  SPEAKER_00: Is it more of like the joint is just really irritated and swollen and it won't access that position?
• 30:09
  SPEAKER_00: And over time, as we put a plan in play, get it calmed down and quiet, the muscle is not guarding, that we can essentially like kind of stretch into that position with proper techniques and exercises and frequency, or is this something that it just won't budge?
• 30:25
  SPEAKER_00: It'll rebound back.
• 30:26
  SPEAKER_00: And if so, then we gotta look at this further.
• 30:29
  SPEAKER_00: And yes, I'm talking about scar tissue or a cyclops lesion that could be playing into this.
• 30:34
  SPEAKER_00: One of our athletes had described it as getting a sweater stuck in a door jam.
• 30:39
  SPEAKER_00: That's kind of how it feels.
• 30:41
  SPEAKER_00: Like when he goes to close the door, that's kind of how it feels trying to get into extension is a sweater and a door jam.
• 30:46
  SPEAKER_00: And our team, we were just like, man, that's a really good way to put a cyclops lesion, is that you can kind of get it there when you forcefully, but it just doesn't stick into that extension.
• 30:58
  SPEAKER_00: And the last thing here is that just knowing extension can regress.
• 31:04
  SPEAKER_00: You work on it, you get it, and then you just put it in the back rear view, right?
• 31:09
  SPEAKER_00: And that's the thing that happens is you don't check it and it kind of slips away.
• 31:14
  SPEAKER_00: So you need to make this a part of your regular kind of audit routine of your knee.
• 31:19
  SPEAKER_00: A heel pop test on both sides regularly.
• 31:22
  SPEAKER_00: It takes no time whatsoever, and once you get it, maintain it.
• 31:26
  SPEAKER_00: That is something I show every athlete, all of our athletes do.
• 31:29
  SPEAKER_00: We have audits where they just kind of look at this and be able to just look at it through the process and see if it feels off or not.
• 31:37
  SPEAKER_00: And sometimes people do have that regress a little bit, and it might just not have had enough attention, especially when you get more into heavier loading phases.
• 31:46
  SPEAKER_00: And so if they're matching, great.
• 31:48
  SPEAKER_00: If not, we adjust and we need to work on it and make sure it is maintained throughout this process, and that is your knees normal.
• 31:57
  SPEAKER_00: And so here's what I want you to walk away with extension is priority number one, and it does not fix itself with time.
• 32:06
  SPEAKER_00: The goal is your uninvolved side.
• 32:09
  SPEAKER_00: Do not get to zero or whatever is flat on the ground.
• 32:12
  SPEAKER_00: Like we needed to match your uninvolved side with the caveat of hypermobile people.
• 32:18
  SPEAKER_00: The test that we're gonna be looking at is the heel pop test.
• 32:22
  SPEAKER_00: We're gonna look at it actively and passively on both sides and write down what you feel with that, and then also record it from the side and also from the bottom of your feet.
• 32:33
  SPEAKER_00: Let's see what the differences are.
• 32:35
  SPEAKER_00: Let's put some objective numbers around this.
• 32:37
  SPEAKER_00: If passive isn't there, active cannot get there.
• 32:41
  SPEAKER_00: Find out why.
• 32:42
  SPEAKER_00: Play detective and work with your physical therapist, and if they say it'll get better with time, or it'll you know, iron out, or you know, zero is fine, then go find a different PT.
• 32:56
  SPEAKER_00: I would say most good knee and ACL PTs are not the ones saying that.
• 33:00
  SPEAKER_00: They are going to be like, we need to get it matching the uninvolved side.
• 33:04
  SPEAKER_00: So if passive isn't there, active can't get there, and you need to figure out why, and don't kick the can down the road.
• 33:11
  SPEAKER_00: Get it assessed, get it planned in place, and I promise you it can save you a headache six months down the road, nine months down the road, or if you're like this guy, he is 12 months from that first imaging and now having to go get this thing cleaned out because no one paid attention to it earlier, and then we just had some imaging done again as he just joined to be able to say, okay, this is the problem, let's go get it cleaned out and let's hit the road to recovery.
• 33:38
  SPEAKER_00: And that's gonna fix the issue, and then therefore he's gonna be able to put it behind him.
• 33:42
  SPEAKER_00: But that could have been done before.
• 33:43
  SPEAKER_00: But there needs to be a plan in place and someone who is checking this for you and connecting the dots, and then just recheck it regularly.
• 33:51
  SPEAKER_00: If it regresses, put a plan in place, work on some of those things.
• 33:55
  SPEAKER_00: It is such a foundational piece of this ACEL rehab process.
• 33:59
  SPEAKER_00: And if you take one thing from this, just make it that good enough, does not work in extension.
• 34:06
  SPEAKER_00: You gotta make sure you get it back.
• 34:08
  SPEAKER_00: And if you want help auditing this, if you feel like you're the one stuck in this, we're here to help.
• 34:13
  SPEAKER_00: You know where to find us.
• 34:14
  SPEAKER_00: We have our information in the show notes.
• 34:17
  SPEAKER_00: We're helping many ACLers navigate this process who are having just such challenging issues, or you know, people are not listening to them, or they feel like they're crazy.
• 34:26
  SPEAKER_00: And we're connecting the dots on these things and we're trying to help you figure that out.
• 34:30
  SPEAKER_00: Or if you're just feeling like you need structure, you're feeling like you need targets, we are here to help, or even point you in the right direction.
• 34:37
  SPEAKER_00: So you feel like you're not the one who is having to shoulder this process.
• 34:42
  SPEAKER_00: Most importantly, advocate for yourself because this world and this kind of space is messy, and it's really important to just make sure that you are the only one that can look out for your knee.
• 34:54
  SPEAKER_00: And it's something that is so important for the short term, but especially the long term, and especially for our mental health.
• 35:01
  SPEAKER_00: We all need to get back to where we want to be, and it starts with making sure that we do this process right and have the right people alongside us.
• 35:09
  SPEAKER_00: So if you need anything, we're here to help.
• 35:11
  SPEAKER_00: I hope that this was helpful.
• 35:13
  SPEAKER_00: Do your knee extension audits.
• 35:16
  SPEAKER_00: And if you find another ACLer who is having issues, send this to them as well.
• 35:20
  SPEAKER_00: Otherwise, I'm gonna close out this episode.
• 35:22
  SPEAKER_00: This is your host, Robbie Patel, signing off.