Latest / The ACL Athlete Podcast / 193 | Navigating Hyperextension in ACL Rehab: When Equal Isn't the Goal

Transcript

193 | Navigating Hyperextension in ACL Rehab: When Equal Isn't the Goal · 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.
• 1:06
  SPEAKER_00: So today I want to talk about a situation where you may not need to get full hyperextension matching the uninvolved side.
• 1:15
  SPEAKER_00: So I'm gonna read this comment and question from an ACLer I got, and I want to dive into a little bit of detail here because extension is something we are always chasing immediately post-injury and post op.
• 1:29
  SPEAKER_00: And this might be a situation where we might not try to get matching the other side.
• 1:34
  SPEAKER_00: So let's talk about this question here first, and then we'll get into it.
• 1:39
  SPEAKER_00: So this ACLer says, the one thing that I just don't know what to think about is hyperextension.
• 1:46
  SPEAKER_00: I know your podcasts say that you should get equal hyperextension to the non-operative knee.
• 1:51
  SPEAKER_00: However, my knees hyperextend quite a bit, over 10 degrees.
• 1:56
  SPEAKER_00: I've gotten the heel pop in my operated knee a while ago and was working hard to get it equal.
• 2:02
  SPEAKER_00: Then I started getting popping in the lateral side of the back of the knee with some pain, nothing too major during hyperextension.
• 2:09
  SPEAKER_00: And my PT suggested to stop working on the hyperextension, as that could be causing it.
• 2:14
  SPEAKER_00: Um, the surgeon also agreed with that and was happy with the hyperextension that I'm at, around five degrees, negative.
• 2:22
  SPEAKER_00: My gait is good, but when I'm standing, I don't feel balanced on both legs.
• 2:27
  SPEAKER_00: My question is if you ever have times where equal hyperextension is not the goal.
• 2:33
  SPEAKER_00: And I think this is a very good question and something I haven't talked about on the podcast because it doesn't apply to the majority of people, but I do think that there is a subset of humans that exist in this world that don't need to get full hyperextension matching the other side.
• 2:49
  SPEAKER_00: So that's what this episode is going to try and tackle.
• 2:53
  SPEAKER_00: So she brings up a very, very good point.
• 2:56
  SPEAKER_00: Basically, her being hypermobile is what we call it, where she can get beyond minus 10 degrees of hyperextension.
• 3:04
  SPEAKER_00: And so she's able to achieve the heel pop, she's able to do like you know, normal walking, but she doesn't feel balanced on both legs, which is normal in this situation.
• 3:16
  SPEAKER_00: When you think about the awareness, everyone kind of knows, even if you're someone who doesn't have full hyperextension and not excessive range of motion on the other side, when you're standing, you kind of notice all right, your knee might be in a little bit of a more locked out position on the unoperated or uninvolved side.
• 3:34
  SPEAKER_00: And then on the involved side, if you're still trying to get your extension back, you kind of notice a little bit of bend in it, or it just doesn't feel equal to the other side.
• 3:42
  SPEAKER_00: Now, with this athlete, she actually feels the opposite.
• 3:46
  SPEAKER_00: It's where her hyperextension isn't matching her very excessively hyperextended knee, if that makes sense.
• 3:52
  SPEAKER_00: So one is probably minus 15 or so, and then her ACL operated side is sitting somewhere around five to 10 degrees, so it still feels off.
• 4:02
  SPEAKER_00: And that's okay in this situation.
• 4:04
  SPEAKER_00: Now I want to get into the details of this and understand the background of it.
• 4:09
  SPEAKER_00: So basically, what we're talking about in this situation is an athlete who is hypermobile.
• 4:15
  SPEAKER_00: Hypermobility is something where your collagen in your joints is just a different ratio, and so it creates more laxity around the ligaments and the soft tissues in the joints, um, aka creating more hypermobility.
• 4:30
  SPEAKER_00: So basically, these are super, super flexible people, and it could be more so related to women than men, but it still can happen in men, of course.
• 4:41
  SPEAKER_00: But we know that just the flexibility of women in in nature and just the genetics of it, it tends to lean in that direction.
• 4:48
  SPEAKER_00: And most athletes I do know who are hypermobile tend to be more female than it is male.
• 4:54
  SPEAKER_00: And so this is something that I see with my ACLers, especially if you fall into this category.
• 5:00
  SPEAKER_00: And so what happens in this situation is that this can be assessed a number of different ways depending on how it manifests itself.
• 5:09
  SPEAKER_00: The easiest and most common way that people will look at it, even as physical therapists, what we will assess is a Baton score.
• 5:16
  SPEAKER_00: And so this is uh a test where you do five different tests and you can score a total of nine points on it.
• 5:24
  SPEAKER_00: And so four are done on the left and the right, and then one is done at your trunk where you're just leaning to touch the ground.
• 5:31
  SPEAKER_00: Can you put your palms on the ground?
• 5:33
  SPEAKER_00: And then others are where do you have elbow hyperextension, knee hyperextension beyond 10 degrees?
• 5:39
  SPEAKER_00: Um, you have a pinky coming towards the back of your forearm, if you will, your thumb coming towards your wrist.
• 5:46
  SPEAKER_00: So if people can excessively like touch those particular areas or have excessive range of motion, and they score four out of the nine, then therefore that is a positive bait and score.
• 6:01
  SPEAKER_00: So basically saying you are hypermobile.
• 6:04
  SPEAKER_00: Now, there's ranges in the research, but this is a general rule of thumb here for this particular situation where someone is hypermobile.
• 6:12
  SPEAKER_00: So then if you notice yourself like that, then you are likely someone with hyperextension at your knees that is pretty excessive, if you will, more than typically 10 degrees.
• 6:24
  SPEAKER_00: And so there can be some other genetic components for hypermobility, but then also aside from hypermobility, it could also be someone who's just naturally born with excessive hyperextension, not a hypermobile athlete, but someone who just has very hyperextended knees, and that can also exist.
• 6:43
  SPEAKER_00: Of course, this is not the quote unquote norm, but the thing is that people have these types of situations when they're born are based on genetics.
• 6:53
  SPEAKER_00: And so the usual kind of range of motion, if you will, for this is beyond negative 10 degrees of hyperextension.
• 7:02
  SPEAKER_00: And so that usually is a fair cutoff because what we typically see with knee extension, people range anywhere from zero to minus 10 degrees of the normative data and somewhere landing in the middle of around minus five, I would say.
• 7:20
  SPEAKER_00: Of knees that I've assessed, people probably sit for the most part around minus five.
• 7:25
  SPEAKER_00: Very rarely are they sitting at zero degrees, which is not full knee extension for majority of human beings.
• 7:32
  SPEAKER_00: Um, it's usually somewhere in the negative, somewhere around five, and it can go all the way towards 10 for normative values.
• 7:40
  SPEAKER_00: So then, therefore, when you get outside of the minus 10 into minus 15, 20, you know, it can even go beyond that, which exists, then therefore you might be categorized into this hyper mobile group or just excessive hyperextension.
• 7:56
  SPEAKER_00: And so your goal is essentially if you are normal in this range, not hypermobile in a sense, right?
• 8:04
  SPEAKER_00: And we're all looking at this based on the uninvolved side, then our goal with ACL rehab is typically to try and get you to match the uninvolved side with that heel pop and getting that ASAP post op.
• 8:18
  SPEAKER_00: Now, if you are in this hypermobile group or just have excessive hyperextension, if you will, into that minus 10 plus into 20 degrees, what I will do in this case is we will work to get you back towards around minus five degrees of extension and then let the rest come.
• 8:38
  SPEAKER_00: We're not trying to push you back to minus 15, minus 20.
• 8:43
  SPEAKER_00: And the thing that I'm looking at is can we get a really solid quad contraction on the involved side?
• 8:51
  SPEAKER_00: And with other movements where we need normal hyperexion of the knee, do they look good from a movement quality standpoint?
• 8:58
  SPEAKER_00: So if we're looking at gait, if we're looking at any positions where it might be acceleration based, where there's triple extended positions, um, to be able to just kind of see can that knee get into position and be able to produce the force and be able to bend and extend in the appropriate ways without there being too many compensations and the appropriate muscles that need to be engaged.
• 9:21
  SPEAKER_00: Then I'm not too worried about it.
• 9:23
  SPEAKER_00: And then we let the rest come versus aggressively working into minus 10, minus 15, minus 20 degrees of extension.
• 9:32
  SPEAKER_00: And then the thought here is that we've established the prerequisites and the adaptations we needed with getting towards minus five and then them being able to do all their movements and engage their quads really well.
• 9:46
  SPEAKER_00: Now, some considerations about this.
• 9:49
  SPEAKER_00: What if this hypermobility or the excessive range of motion was a player, a factor into the injury initially that happened?
• 10:00
  SPEAKER_00: Maybe, maybe not.
• 10:02
  SPEAKER_00: I can't really say and prove that, but this is going to be very dependent on the injury itself.
• 10:08
  SPEAKER_00: But a less stable joint, if you will, with lots of range of motion leans towards a higher risk just due to the nature of it being less stable, if you will, given the hypermobility.
• 10:19
  SPEAKER_00: Um, I've had athletes who easily dislocate, they range on this hypermobility scale, and they'll have joints that can sometimes dislocate.
• 10:30
  SPEAKER_00: Um, and it's just something where the joints don't feel as stable, they feel very flexible, there's a lot of excessive range of motion.
• 10:38
  SPEAKER_00: And so, in situations like this, what we want to ultimately do as a physical therapist, as a performance coach, is to create stability because they have a lot of mobility.
• 10:50
  SPEAKER_00: So then, therefore, we want to try and stabilize the system in order to find a delicate balance between the two.
• 10:57
  SPEAKER_00: And so then for our hypermobile athletes, this means decreasing that excessive movement and degrees of freedom, if you will, that excessive range of motion by making the supporting tissues around it stronger to provide more stability.
• 11:12
  SPEAKER_00: So that's where strength training really does come into place.
• 11:16
  SPEAKER_00: Can we really affect the soft tissues in terms of like the collagen and the ligaments and things of that nature?
• 11:23
  SPEAKER_00: Not necessarily, but with the supporting structures, just even think about what we do with a torn ACL that's non-operative, right?
• 11:32
  SPEAKER_00: We're gonna try and create a stable joint to support it by making all the muscles around it much stronger.
• 11:38
  SPEAKER_00: So, in this same situation, if we have more lax ligaments or more degrees of freedom, we're gonna try and strengthen everything to help support that as much as we can.
• 11:49
  SPEAKER_00: So, in a situation like this, we are not trying to force excessive hyperextension to 15 to 20 degrees in the negatives.
• 11:59
  SPEAKER_00: We will try to get them towards minus five and then allow the rest of it to come and just continue to assess and see.
• 12:06
  SPEAKER_00: One thing that is interesting, and as this athlete reported, was that as she started to work into more and more extension, she started to notice just discomfort in the back of the knee, um, some popping.
• 12:19
  SPEAKER_00: And this is actually something that I've noticed some athletes when they get their hyperextension, and especially someone who isn't even hypermobile, um, you know, I've had athletes that they really take, hey, let's get that heel pop and extension back ASAP.
• 12:36
  SPEAKER_00: And um, I'll see them a week or two later, depending on our frequency.
• 12:41
  SPEAKER_00: And this is something where they've come in and they're like, Yeah, the back of my knee is starting to get like really sore.
• 12:48
  SPEAKER_00: And I'm starting to get like this like discomfort.
• 12:51
  SPEAKER_00: And I start to see that their heel pop is almost higher than their uninvolved side.
• 12:55
  SPEAKER_00: And so that's where I'm like, all right, yeah, we just want to match the uninvolved side, and then from there, we are good if we are talking about a normal knee anatomy and range of motion.
• 13:07
  SPEAKER_00: And with this athlete, she felt it with getting into the hypermobile positions, the minus 15 or so.
• 13:15
  SPEAKER_00: And so that played a role into potentially how our knee was responding to that.
• 13:19
  SPEAKER_00: It's normal to have some stretch and kind of discomfort in the back of the knee, but it is always in comparison to the uninvolved side, and also what we would want to establish as your normal.
• 13:32
  SPEAKER_00: If you are um someone who is not hypermobile, we're trying to match the uninvolved side, and then we're good to go.
• 13:37
  SPEAKER_00: Don't feel like you need to keep going more and more.
• 13:40
  SPEAKER_00: And that's where some of these athletes start to have some like discomfort issues um with their knee and in the back of the knee, especially, or feeling some excessive popping.
• 13:51
  SPEAKER_00: And so then that's where we're like, hey, we're good with just where we need to match it.
• 13:55
  SPEAKER_00: And so this is just some consideration for working with athletes and you ACLers who might be in this hypermobile scenario where we want to make sure how we can make sure the extension itself is getting back to a place where it's gonna help to make sure you can walk normal and also um for the long term in terms of getting back to your sport and not being too worried, did I get enough of it?
• 14:24
  SPEAKER_00: Did I get too much of it?
• 14:25
  SPEAKER_00: So hopefully this is helpful.
• 14:27
  SPEAKER_00: And of course, this is a case-by-case basis for my hypermobile athletes, but this is where you have to consult with your surgeon and with your physical therapist.
• 14:36
  SPEAKER_00: But for me, it always comes back to what are the things that we are trying to get back to in terms of walking, in terms of just different movements, and can we get the quads going?
• 14:48
  SPEAKER_00: And if that's the case, we're probably in a pretty solid spot to be able to move forward with our knee extension and let the rest of it come.
• 14:56
  SPEAKER_00: So I hope that this was helpful, team.
• 14:58
  SPEAKER_00: Until next time, this is your host, Robbie Patel, signing off.