Latest / The ACL Athlete Podcast / 251 | Knee Flexion Truths in ACL Rehab: What’s Normal, What’s Not, and What Actually Matters

Transcript

251 | Knee Flexion Truths in ACL Rehab: What’s Normal, What’s Not, and What Actually Matters · 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 am keeping it super short and sweet, and I want to talk about one thing in particular knee flexion.
• 1:15
  SPEAKER_00: This is where you bend your knee or bring your heel towards your butt.
• 1:19
  SPEAKER_00: One of the common goals along with extension when you're post-injury and post-op ACL.
• 1:26
  SPEAKER_00: And so when we are early on, we are trying to restore both knee extension and knee flexion.
• 1:34
  SPEAKER_00: And I've done an episode on this before of which one should you prioritize post-ACL surgery.
• 1:39
  SPEAKER_00: So if you have not caught that, that's episode 190 where we talk about which one you should prioritize.
• 1:47
  SPEAKER_00: Now, I'm just gonna kind of give you the brief cliff notes here because it's gonna help me lead into flexion conversation here.
• 1:55
  SPEAKER_00: And really, we are trying to prioritize extension first.
• 1:59
  SPEAKER_00: We want to make sure that we can get that heel pop, making sure the best test is to look at when you sit down on a floor and you have both legs extended out, you're on a hardwood floor, you do a quad set where you activate that quad.
• 2:16
  SPEAKER_00: And usually on the uninvolved side, that heel will raise up, even if it's just a little bit, we call that the heel pop test.
• 2:22
  SPEAKER_00: And then on the involved side, we want to get that matching.
• 2:26
  SPEAKER_00: That is basically a proxy, a test.
• 2:28
  SPEAKER_00: If you can get that to match your uninvolved side, then you're in a good spot for extension, right?
• 2:33
  SPEAKER_00: And we want to prioritize that as number one post op.
• 2:36
  SPEAKER_00: Now, what happens is that people will often work on flexion more.
• 2:41
  SPEAKER_00: There's not as many degrees to work on with extension, and it also depends on how much your physical therapist, your surgeon might prioritize extension or really encourage you to get that.
• 2:52
  SPEAKER_00: We see a lot of times people are aiming to get to zero when in reality we need to match hyperextension of what the uninvolved side is.
• 3:00
  SPEAKER_00: Only caveat is if you have excessive hyperextension, we're talking about minus 15 degrees of hyperextension, which is not majority of you.
• 3:08
  SPEAKER_00: It's like 5% of people if that.
• 3:10
  SPEAKER_00: So, with that said, like most people need to get beyond zero to get terminal knee extension, that heel pop that we are looking for.
• 3:18
  SPEAKER_00: Now, the focus here is on flexion.
• 3:20
  SPEAKER_00: And the reason I'm bringing this up is because a lot of times people will be like, Well, I'm not at a certain point with flexion.
• 3:26
  SPEAKER_00: And I will say that this will vary across the board for people.
• 3:30
  SPEAKER_00: Now, for us at the ACL athlete, we are aiming for within the first two weeks, and let's assume there's no restrictions like a meniscus repair.
• 3:38
  SPEAKER_00: Even if you have a meniscus repair, usually that can be limited to maybe 90 degrees of flexion in the first two to four weeks, for example.
• 3:47
  SPEAKER_00: It can vary across the different repairs and protocols and surgeons' restrictions.
• 3:52
  SPEAKER_00: But with that said, let's just talk about without any type of other additional repairs.
• 3:56
  SPEAKER_00: You're talking about ACL only.
• 3:59
  SPEAKER_00: We're gonna aim to try and get to knee flexion within two weeks.
• 4:02
  SPEAKER_00: And we're gonna try and get there at 90 degrees.
• 4:05
  SPEAKER_00: That would be an ideal time point for us to say, like, all right, if we can get to 90, we're in a good spot at that point, right?
• 4:10
  SPEAKER_00: And then within four weeks, we're looking to try and get towards 120 degrees.
• 4:15
  SPEAKER_00: So that's really our focus there.
• 4:17
  SPEAKER_00: And then, of course, we have ranges depending on the repairs, as I had shared.
• 4:22
  SPEAKER_00: Even if you have a repair and you have 90 degrees from the get-go, as like the way the restriction that you have, we still try to get there within two weeks, and then we try to maintain that until you know we get more freedom to be able to get more flexion based on the restrictions.
• 4:38
  SPEAKER_00: Now, a lot of times what people do is that they will focus a ton on flexion and will ignore extension or be like, oh, it's fine, it's straight.
• 4:47
  SPEAKER_00: When in reality, we need to make sure we are prioritizing that extension.
• 4:51
  SPEAKER_00: But the other piece here is I want to talk about is that when people get to 120, usually we're in a good spot.
• 4:58
  SPEAKER_00: So that's usually our threshold where we're like, okay, you'll get the rest of the way there.
• 5:03
  SPEAKER_00: Now that doesn't necessarily mean we let off the gas on working on flexion, but for those of you listening, if you are three months out, if you're four months out and you don't have full end range flexion, and our test for this is essentially doing a tall kneeling rock back.
• 5:19
  SPEAKER_00: So what you do is you're on both knees on the ground and you're gonna just hit your butt back towards your heels, and you're gonna just assess and see, okay, what does that feel side to side?
• 5:30
  SPEAKER_00: It's kind of like a yoga pose that you can kind of see like people are on their yoga mass, and then they just kind of sit back with their shins against the ground and their butts all the way back towards their heel, right?
• 5:40
  SPEAKER_00: Natural sitting position for a lot of people.
• 5:43
  SPEAKER_00: But this is something that we use as an assessment.
• 5:46
  SPEAKER_00: And what you'll notice is that when you go to do that on the ACL involved side, if it's not fully restored yet, you'll feel a little bit of tightness.
• 5:54
  SPEAKER_00: You may feel a little bit of kind of like discomfort in the back side of the knee, or maybe in the front, it just kind of feels like a balloon just because there might be some fluid still in there.
• 6:02
  SPEAKER_00: And this will vary person to person.
• 6:04
  SPEAKER_00: And so, with that said, we're gonna use this as our assessment to help us know, okay, does this person have this fully restored comfortably?
• 6:13
  SPEAKER_00: And we want to get that back, especially if it's sport-based, activity-based, but just from a natural human access to positions, just like we want full extension, we want you to get back full flexion.
• 6:24
  SPEAKER_00: And it's crazy the amount of people that we get who are months and years out who never get it restored, or they get it like 70, 80% there.
• 6:33
  SPEAKER_00: And range of motion is one of those things that is harder to get back the further and further out you are from your injury and from your surgery.
• 6:39
  SPEAKER_00: It's just the tissues naturally just come to a certain point where it's just like doesn't want to go as much, and it kind of gets set in its own particular stiffness, if you will, all the fibers and the different tissues within the knee.
• 6:53
  SPEAKER_00: So that's why we need to maximize this as much as possible within that first early post-op period, but then throughout the process, if it has not been fully restored yet.
• 7:03
  SPEAKER_00: And so when you rock back on your heels, you'll feel that tightness, you may feel some discomfort in the back of the knees.
• 7:09
  SPEAKER_00: I like to have people like hold on to something in front of them, or they could do like a quadruped rock back where their hands are on the ground and rock back slowly.
• 7:16
  SPEAKER_00: But the tall kneeling rock back is our ultimate test and proxy, just like the heel pop test.
• 7:21
  SPEAKER_00: And what we'll normally see is that on the uninvolved side, you know, you'll kind of come back and you'll put more of your weight on that side as you rock back, and then you'll kind of let off a little bit of weight on the involved side.
• 7:31
  SPEAKER_00: And that's because we just don't have it fully restored yet.
• 7:34
  SPEAKER_00: But the main point I want to get across here is that we want to work on this over time, and it's not just like, you know, one full hour session of working on knee flexion.
• 7:45
  SPEAKER_00: Range of motion work is chipping away, just like you're trying to like chop out a tree with an axe, right?
• 7:51
  SPEAKER_00: It's not just gonna be one big chop, it's gonna be chops over periods of time, and it's the same thing here.
• 7:57
  SPEAKER_00: And so the way that we say this is like instead of one big hour-long session, you focus on this.
• 8:03
  SPEAKER_00: I'd rather you spread this out across the day.
• 8:06
  SPEAKER_00: Do it three to five times, even get a few sets in if you can.
• 8:10
  SPEAKER_00: Um, and that's gonna be helpful to just kind of slowly microdo some of that work in, but you're gonna have to chip away at it consistently day over day.
• 8:20
  SPEAKER_00: Now we will have breaks with that with our athletes, of course.
• 8:22
  SPEAKER_00: Like maybe there's a strength training day with a little less uh range of motion work, if you will.
• 8:29
  SPEAKER_00: They're working on range of motion through their strength work, but then we might have the mobility work be a little less in volume on that day, and then there may be rest or recovery days where they're focusing a little bit heavier on range of motion work.
• 8:42
  SPEAKER_00: But it's not going to be once or twice a week and you expect to move the needle with mobility, especially for knee extension reflection.
• 8:49
  SPEAKER_00: It's going to be chipping away at it consistently, you know, five, six days a week to be able to make sure you move the needle with that.
• 8:56
  SPEAKER_00: So I think that's super important to share with you guys and also to know that everyone kind of ranges in terms of restoration of this, while we aim for the two-week mark for 90 and four-week mark for 120.
• 9:08
  SPEAKER_00: Not everyone hits that perfectly.
• 9:10
  SPEAKER_00: And the thing is that we are aiming towards 120.
• 9:13
  SPEAKER_00: And then once you get past 120, I will say that if you continue to just work on it, be consistent, it will come.
• 9:21
  SPEAKER_00: And everyone that we work with, to be honest, once we hit that point and once we continue to chip away at it, they end up getting there.
• 9:28
  SPEAKER_00: It might take some people, you know, maybe the four, six weeks, and there are some people who just get there and it's magical.
• 9:36
  SPEAKER_00: And there's some people it takes six months, y'all.
• 9:39
  SPEAKER_00: It takes nine months, and it's one of those things that I wish there were like very clear-cut, this is exactly why.
• 9:47
  SPEAKER_00: But in reality, everyone's kind of on their own journey.
• 9:49
  SPEAKER_00: There are so many contextual factors between life and all the other things they're dealing with, the surgery itself, the injury itself, um, all kinds of other personal factors going on, the rehab they're doing.
• 10:01
  SPEAKER_00: So there are a lot of layers to this.
• 10:04
  SPEAKER_00: And so it's something that I think is important to share with you guys.
• 10:08
  SPEAKER_00: Let's prioritize extension, but for flexion, once you get past 120, keep working on it, but don't feel like you need to spend all the time in the world working on it and keep chipping away, especially at making sure your extension restores properly, making sure your quads are active and working, making sure your swelling goes down, especially.
• 10:27
  SPEAKER_00: That's the biggest one I see.
• 10:29
  SPEAKER_00: People have breaks in their process because they are just constantly dealing with even low levels of swelling, and then making sure that that strength is progressing appropriately.
• 10:39
  SPEAKER_00: And so those are the pieces that we need to kind of bucket and work on through this process.
• 10:44
  SPEAKER_00: And so then, therefore, you can work on that flexion, work on the extension, prioritize extension, but then also with flexion, get it to those certain points and then just kind of layer that stuff in and chip away at it, even as you get into the later parts of the process.
• 11:00
  SPEAKER_00: And if you do this properly over the course of months and months, then you will be able to get to that knee flexion and it can have some variability in those end ranges.
• 11:11
  SPEAKER_00: I would say the last 10, 20% sitting back fully on your heels takes a little bit more time.
• 11:16
  SPEAKER_00: So just keep chipping away at it.
• 11:18
  SPEAKER_00: We've had people who join us, you know, at six months or eight months or even years out.
• 11:22
  SPEAKER_00: They just never did intentional work on it.
• 11:24
  SPEAKER_00: And then eventually they layered that in.
• 11:27
  SPEAKER_00: And, you know, within four weeks, six weeks, they get there.
• 11:30
  SPEAKER_00: Some people take longer, some people take shorter.
• 11:32
  SPEAKER_00: It's just all about making sure you have the right prescription, making sure there is objective testing with it, and then being able to assess and adapt the program as you go.
• 11:41
  SPEAKER_00: So I hope this is helpful, y'all.
• 11:42
  SPEAKER_00: Less than 10 minutes was my goal, and I hope that we hit it.
• 11:46
  SPEAKER_00: Maybe, but we will see.
• 11:48
  SPEAKER_00: All right, team.
• 11:49
  SPEAKER_00: Until next time, this is your host, Fravi Patel, signing off.