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195 | One Common Mistake ACLers Make When Working on Knee Extension · 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.
• 1:00
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:07
  SPEAKER_00: First, I just want to stop for a second.
• 1:09
  SPEAKER_00: I want to say thank you to all of you who have reached out and just said how much they appreciate the podcast and how it's helped you in your journey.
• 1:18
  SPEAKER_00: I get messages every single week, and it is awesome to hear how you guys are putting this stuff in play, how it's been helpful, whether you decided to go in a different route with your physical therapist.
• 1:28
  SPEAKER_00: Maybe it is finding a second opinion, maybe finding some testing for you, or just the mindset pieces that I'm hoping that you're able to pull away from these episodes.
• 1:39
  SPEAKER_00: So please keep the messages coming.
• 1:41
  SPEAKER_00: As you know, in the show notes, there are opportunities and ways for you to send me a direct comment.
• 1:48
  SPEAKER_00: Um, and it's nothing where I know what your number is, you can text it directly to me, you can send me a message through Instagram, email, and I get all these.
• 1:57
  SPEAKER_00: I read all of them and I reply back to all of them.
• 2:00
  SPEAKER_00: And so I just want to say thank you so, so much because I have so much gratitude towards you guys and this space.
• 2:08
  SPEAKER_00: And as we just continue to try and move the needle and help as many ACLers and just the whole profession of physical therapists and coaches who are working with this and surgeons, we're all trying to do the thing.
• 2:20
  SPEAKER_00: So I appreciate all of you guys, and I'm gonna continue to try and put out as much as I can to help you guys through this process and just share my experiences, and that way we can one day say maybe re-injury rates are dropping, and that we can get people back to sport without there being this fear around this injury, and there's better care serving all of you guys.
• 2:43
  SPEAKER_00: So thank you so much.
• 2:45
  SPEAKER_00: Now, on to the episode for today.
• 2:48
  SPEAKER_00: So, after an ACL injury and surgery, one of our top goals, if not the number one goal, is to regain knee extension.
• 2:59
  SPEAKER_00: What I often share with athletes is the heel pop.
• 3:02
  SPEAKER_00: So that is essentially a test for you to be able to do to assess and see am I able to do what I need to do with my knee extension?
• 3:12
  SPEAKER_00: That basically clears two things for us.
• 3:15
  SPEAKER_00: One is making sure that you have your matching knee extension and that your quads are active to do it, right?
• 3:21
  SPEAKER_00: So our goal is hyperextension matching the uninvolved side outside of someone who is extremely hypermobile and has like minus 15 or 20 degrees of hyperextension.
• 3:31
  SPEAKER_00: And there are other cases as well, but for 95 to 98% of you guys, you're going to be aiming to match your extension as the other side, assuming it has not been injured, right?
• 3:44
  SPEAKER_00: And so the way you can do this is essentially get on the ground or on a table, and you're essentially going to use your uninvolved side as your target, and you're gonna do a quad set, right?
• 3:55
  SPEAKER_00: So the goal is to try and lift the heel and the foot.
• 3:58
  SPEAKER_00: Um, you're almost bringing like your toes towards your nose, right?
• 4:00
  SPEAKER_00: And you're doing that quad set, which is the staple of every single basic exercise given after a knee injury, but especially after ACL injury and surgery, right?
• 4:10
  SPEAKER_00: It's on that post-op sheet of paper that you get.
• 4:13
  SPEAKER_00: It's the number one thing that your physical therapist will give you after a knee issue and especially after surgery and injury.
• 4:21
  SPEAKER_00: So that quad set is going to be essentially what you're gonna do.
• 4:24
  SPEAKER_00: And that's where we're trying to aim to get that heel pop.
• 4:26
  SPEAKER_00: So if you do it on your uninvolved side, your heels should kind of lift off the ground and there should be a little bit of space underneath the heel and the floor, or whether it's on a table that you're sitting on, but that should allow your quads to activate and your heel comes off the ground.
• 4:41
  SPEAKER_00: The back of the knee is flush to the ground ideally, but we are not kicking in with our heels as well while we're keeping the back of the knee down and doing a quad set.
• 4:50
  SPEAKER_00: And so, again, as I had mentioned, the goal of this quad set is always twofold.
• 4:54
  SPEAKER_00: One is to wake up the quads after this injury and surgery and get them active and firing, right?
• 5:00
  SPEAKER_00: We want to wake them up because we know that they can get kind of sleepy in this process, especially after the surgery.
• 5:06
  SPEAKER_00: And then the other thing is that we are also trying to regain that full knee extension.
• 5:10
  SPEAKER_00: So that's number two for that quad set and the goal and the purpose of it.
• 5:15
  SPEAKER_00: I see often that what is overlooked and butchered a lot is this movement.
• 5:21
  SPEAKER_00: And you think it could be straightforward, right?
• 5:24
  SPEAKER_00: But this could be something due to poor guidance on how to do this exact movement.
• 5:30
  SPEAKER_00: And don't forget, like, we are coming into this with kind of our brain and muscle disconnect, especially with the knee.
• 5:36
  SPEAKER_00: We're dealing with pain and swelling.
• 5:38
  SPEAKER_00: There's a lot of pieces that are in play.
• 5:40
  SPEAKER_00: And I remember for both of my ACLs, immediately after surgery, it was challenging to get that quad set, right?
• 5:47
  SPEAKER_00: Like there's apprehension, there is the pain, of course.
• 5:51
  SPEAKER_00: You're just like, am I gonna mess something up?
• 5:53
  SPEAKER_00: And you're also dealing with inhibition of the knee itself, too, right?
• 5:57
  SPEAKER_00: So this is something that I think for especially physical therapists who haven't gone through a knee injury like this and who have not had to deal with something like this, like a you know, an ACL reconstruction, and it can easily get overlooked as a very basic exercise.
• 6:13
  SPEAKER_00: How can you mess this up?
• 6:14
  SPEAKER_00: Right.
• 6:15
  SPEAKER_00: And on looking at it, sure, but there are so many people where it could be really challenging.
• 6:22
  SPEAKER_00: So this comes back to is it because of poor guidance on how to do the movement?
• 6:27
  SPEAKER_00: Um, maybe it's the cueing of it, understanding the setup of it.
• 6:31
  SPEAKER_00: Um, but it can often be overlooked because of the simplicity of it, or maybe the PT doesn't have enough time to look at the details of it or how you're firing and doing the actual quad set.
• 6:42
  SPEAKER_00: But this is something that I think is important to slow down and make sure you're doing well and doing it right.
• 6:48
  SPEAKER_00: And so, with that said, the other piece of this too could be maybe you are getting good guidance on it, but you are dealing as the athlete and ACLer with swelling, with pain, with inhibition, with apprehension about messing something up, or you know, just moving the knee itself.
• 7:04
  SPEAKER_00: You just had a major surgery.
• 7:06
  SPEAKER_00: So that's warranted, right?
• 7:08
  SPEAKER_00: And that is totally normal to feel.
• 7:10
  SPEAKER_00: And so, what I want to make sure with this episode is to point out something that is a common mistake I see that doesn't get discussed very much in the space.
• 7:21
  SPEAKER_00: I think it's just like, hey, work on your quads, work on your extensions, hang it up, do some bag hangs, you know, do all these different exercises.
• 7:28
  SPEAKER_00: But like, I want to point out some things that I see that uh that can be hopefully helpful for you, right, as an ACLer.
• 7:36
  SPEAKER_00: And especially for those people who it might not just come back naturally in those first couple of weeks.
• 7:43
  SPEAKER_00: Dealing with extension, maybe it's taking its sweet time to get back, and the quads are staying a little bit more asleep.
• 7:49
  SPEAKER_00: So then, therefore, this especially applies to you guys because there are people who get extension right off the bat.
• 7:55
  SPEAKER_00: They don't have any issues, and that's great for you.
• 7:58
  SPEAKER_00: But there is also a very large group of ACLers who struggle to get extension back, and that could be for a number of reasons from the injury to the surgery to the graph type, to maybe there is a nerve block to maybe there is some other like cur kind of neurological factors in play.
• 8:17
  SPEAKER_00: Um, we know that the knee and the quad shuts down through AMI, artrogenic muscle inhibition, and there's some sort of like weird brain, muscle, knee connection that it's almost like the battery has been disconnected.
• 8:31
  SPEAKER_00: And there's even a subset of these people, right?
• 8:33
  SPEAKER_00: And so then, therefore, I do want to make sure that it's understood.
• 8:38
  SPEAKER_00: Yeah, we have an expectation to get this ASAP, but it can take some time.
• 8:42
  SPEAKER_00: And so then, therefore, I want to make sure that you're equipped to know one of the things to look out for, especially if you're someone who maybe doesn't get the extension back ASAP.
• 8:53
  SPEAKER_00: And so then, therefore, you are fighting really hard to work on it, work on these quad sets, because I'm sure you will do hundreds and hundreds and thousands of these over the course of ACL rehab, especially if you're trying to get your knee extension back.
• 9:04
  SPEAKER_00: So, the common mistake that I see when athletes are especially doing a quad set specifically, so working on this heel pop, trying to get that full knee extension, getting the quads active, is that their hamstrings and glutes can sometimes take over.
• 9:21
  SPEAKER_00: And if someone is having a harder time with this extension, the movement itself can be a little bit deceiving to them and potentially the PT too, thinking that they're getting a good quad set and that extension when in reality they're actually kicking on their glutes and hamstrings while some quad tone might be showing up.
• 9:45
  SPEAKER_00: And this is especially true for my ECLers who have maybe more of a little bit muscular build.
• 9:51
  SPEAKER_00: Um, the defined folks, where obviously you know you're a little bit leaner.
• 9:56
  SPEAKER_00: And this is something where I notice where you know they'll go to do a quad set or they're working on this knee extension, and it's something where they'll start to fire their glutes and hamstrings.
• 10:07
  SPEAKER_00: Like I'll see their kind of hip kind of lift.
• 10:09
  SPEAKER_00: And when you do a quad set, you'll kind of see some movement lift in that thigh and in the glute a little bit.
• 10:15
  SPEAKER_00: But that's where it's challenging.
• 10:17
  SPEAKER_00: We got to make sure we we cover the details of this and what's firing and what shouldn't be firing.
• 10:22
  SPEAKER_00: Because what ends up happening is that gluten hamstring kind of contracts with it, and the quad will, you know, it it's not like it's completely asleep.
• 10:31
  SPEAKER_00: Maybe you are have been working at it, and it's it's kicking on a little bit, right?
• 10:36
  SPEAKER_00: But you feel like you're doing it because you don't really know what it should feel like, right?
• 10:42
  SPEAKER_00: And it's more of firing at like 50% of its capacity.
• 10:47
  SPEAKER_00: And so when you're doing that quad set, you're feeling it maybe kick on.
• 10:52
  SPEAKER_00: There's a little bit of tone, there's a little bit of firmness, but you know it's not the same as the other side.
• 10:57
  SPEAKER_00: But you kind of see the leg lift a little bit in terms of like the thigh itself.
• 11:02
  SPEAKER_00: And what I will notice when I observe my athletes is that this is something where if we don't correct this, right?
• 11:10
  SPEAKER_00: They are essentially kind of digging a little bit that, especially the heel is contact with the ground or with the table, they will kind of dig a little bit of their heel or maybe some of their calf, the back of the leg, as they're trying to fire and push the back of the knee down, and it's kicking on the hamstrings and glutes.
• 11:27
  SPEAKER_00: So, what it's causing is this co-contraction.
• 11:30
  SPEAKER_00: So imagine you're kind of looking at someone from the side, they're laying on a table, and when they go to do this quad set, they're trying to essentially keep the back of the knee down while the bottom of that heel lifts and you start to see a gap underneath it where that heel pops up.
• 11:44
  SPEAKER_00: But what ends up happening is that if athletes aren't cued or if they're not, you know, appropriately corrected on this, they'll kind of dig the back of that leg down, especially the heel and the back of that calf.
• 11:56
  SPEAKER_00: And that hamstring and glute, what we're essentially doing is doing an isometric at our hip.
• 12:03
  SPEAKER_00: And so that's creating hip extension.
• 12:04
  SPEAKER_00: So it's firing our glutes, firing our hamstrings a little bit, and it's co-contracting, along with maybe the quads are kicking on a little bit.
• 12:13
  SPEAKER_00: But the thing is, it doesn't feel like it's fully kicking on, and it doesn't feel like the hamstrings and glutes are fully relaxing.
• 12:20
  SPEAKER_00: And so this is something that I do see doesn't get corrected by some ACLers who maybe come to us a little bit later, especially with knee extension issues, maybe an overly tight hamstring.
• 12:32
  SPEAKER_00: Um, maybe it is something where they're still limping with their gait.
• 12:36
  SPEAKER_00: So this is something that's always interesting because maybe they've been given the pass to move on and start doing straight leg raises and you know, all the other things that come along in this process, and they're like, oh, well, yeah, the extension's there, but in reality, it's not.
• 12:52
  SPEAKER_00: And so these same people can sometimes think it's fine and normal.
• 12:56
  SPEAKER_00: And they're the ones who do have this extension and quad activating issues later on down the road.
• 13:02
  SPEAKER_00: And the other thing that I'll see too is that sometimes when I ask them, you know, an ACLer who's six months out dealing with extension issues, they might recruit their hamstrings and their glutes whenever they are contracting their quad in certain situations where it shouldn't be.
• 13:18
  SPEAKER_00: So the firing patterns, almost the brain knows at that point, oh, I need to go into extension, I'm gonna fire my glutes and hamstrings and try to kick on my quads a little bit too.
• 13:28
  SPEAKER_00: So, with that said, I think trying to focus on this isolation piece and really being able to clean up this error can help a lot with people feeling their quads a little bit better, getting this extension back to matching the other side.
• 13:42
  SPEAKER_00: And so, this is one thing that I want you guys to look out for, especially if you're an ACL or listening to this, and you are someone who, you know, you're struggling with your extension.
• 13:52
  SPEAKER_00: And I'm not saying this is gonna solve all of the extension problems in the world for ACLs and knees, but this is something that I see more often than not when someone is not corrected or dealing with extension issues.
• 14:04
  SPEAKER_00: You know, you want to make sure you get that passive range of motion.
• 14:06
  SPEAKER_00: So being able to lift it up passively where it needs to go, but especially with the quad set, being able to make sure that you can lift that heel up and get that heel pop and not kicking into whatever surface you're on.
• 14:21
  SPEAKER_00: And so one of the tricks I like to do with this is removing the tactile sensation behind the heel or behind the calf a little bit where you might be digging in.
• 14:32
  SPEAKER_00: So we're trying to limit the ability or the input of the hamstrings and the glutes.
• 14:37
  SPEAKER_00: And so the way we do that is we need to remove, especially if you're on a table, um, you might be kind of digging your heel down as you're doing a quad set, trying to activate that quad.
• 14:46
  SPEAKER_00: So, what I'll do is have athletes actually scoot off until maybe you know, half of their Achilles or even to the top part of their Achilles will be on the table and their heel is actually off the table.
• 14:58
  SPEAKER_00: And what I challenge you to do here is actually do this on your uninvolved side.
• 15:02
  SPEAKER_00: So have both legs hanging off the table and the back of the Achilles, kind of like where some like low ankle socks would be.
• 15:09
  SPEAKER_00: And you're going to essentially lift up the uninvolved side and you should feel that knee kind of get flush with the surface and lift that heel up, and you'll feel that quad contract and squeeze, right?
• 15:20
  SPEAKER_00: And you're gonna try and do it with the same thing with the involved, the operated side, the injured side, and you're gonna try and do the same thing and see if you can get that to match up.
• 15:30
  SPEAKER_00: And what I find is that if we remove the heel or that tactile sensation on the back of the heel there, then that's gonna help with reducing the activity of the hamstrings and the glutes.
• 15:42
  SPEAKER_00: So this is something that I'm going to actually link.
• 15:46
  SPEAKER_00: I did a video on this on IG showing one of my athletes actually doing that.
• 15:50
  SPEAKER_00: And then what we did was actually have him slide off the table a little bit and cued him a little bit, of course, but reducing that tactile sensation made a huge difference.
• 16:01
  SPEAKER_00: And I think this is something that does get overlooked, and you might end up getting the right firing pattern, but if you're not mindful of it or intentional, I've seen athletes who, you know, they get it one session and they come back in the next session and they're still kind of reverting back to that firing pattern.
• 16:17
  SPEAKER_00: And so then, therefore, we need to clean this up because we want to make sure repetition to repetition is consistent session to session.
• 16:25
  SPEAKER_00: And especially at home, man, you're hitting a lot of reps of this stuff.
• 16:28
  SPEAKER_00: So you are putting deposits into the right type of movements versus choosing to, you know, kind of go through it, but maybe it's not as best as it could be.
• 16:39
  SPEAKER_00: So this is something I want you guys to look out for, especially with the quad set and your knee extension work, because there is not a single human who will walk this earth if they have a knee injury, if you have an ACL injury, a surgery, you will hear of a quad set, or maybe in a different country, it might be referred to something else from a terminology standpoint.
• 17:04
  SPEAKER_00: But it is one of the most basic exercises given.
• 17:06
  SPEAKER_00: And any single post-op sheet of paper that has an exercise on it, it is going to have a quad set on it.
• 17:12
  SPEAKER_00: And so then, therefore, we want to make sure if we're using it, not a bad exercise to kind of get started on it, but with that said, we want to make sure we are very intentional about the details and the way we're executing it because it could be the difference between you not getting that extension in a couple weeks and maybe you're still attacking it three months later, six months later.
• 17:33
  SPEAKER_00: So, just the nuances of this process, I want to make sure I share with you guys and see what I see with my athletes and how we can kind of clean this up.
• 17:40
  SPEAKER_00: So, check out the video, and I hope that this is helpful for you.
• 17:44
  SPEAKER_00: And if you have any questions, you have so many different mediums to reach out and find me.
• 17:50
  SPEAKER_00: If you guys have been getting value from this podcast, I ask you one favor.
• 17:54
  SPEAKER_00: Please rate us, please share that rating for us, and that will be so helpful, whether you're on Spotify, Apple Podcasts, whatever it might be.
• 18:05
  SPEAKER_00: It goes a long way and it helps us reach more and more ACLers.
• 18:09
  SPEAKER_00: And that is the goal.
• 18:10
  SPEAKER_00: How can we shift this landscape and the problems we're dealing with by continuing to educate not only other professionals who are going through this process and being able to work with ACLers, but it's also you as the ACLer yourself, like putting you in the driver's seat, putting you in control of this process.
• 18:28
  SPEAKER_00: So that's what my goal is with this podcast.
• 18:31
  SPEAKER_00: And I appreciate all of you who have been on this ride with me.
• 18:35
  SPEAKER_00: And you know, if you want to chat, if you need any help, reach out to us.
• 18:40
  SPEAKER_00: Otherwise, I will catch you guys next time on the next episode.
• 18:44
  SPEAKER_00: This is your host, Robbie Patel, signing off.