Latest / The ACL Athlete Podcast / 012 | The Importance of Regaining Knee Extension After ACL Injury or Surgery

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012 | The Importance of Regaining Knee Extension After ACL Injury or Surgery · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  SPEAKER_00: This is the podcast where we talk about everything related to the ATL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  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.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:04
  SPEAKER_00: What's up guys?
• 1:05
  SPEAKER_00: Welcome back to the ACL Athlete Podcast.
• 1:09
  SPEAKER_00: So today we're talking about knee extension, why it's important, why should we get it back, uh, what are some of the parameters around it?
• 1:18
  SPEAKER_00: So that'll be the focus today.
• 1:20
  SPEAKER_00: But before we get into it, I just want to say thank you to all of you.
• 1:24
  SPEAKER_00: We just passed 1,000 downloads, which is incredible.
• 1:29
  SPEAKER_00: Uh I thought that my wife was probably just hitting play multiple times and just getting the count up, but it's been really cool to see the support and everyone really just reaching out about this podcast and how it's been helpful or sharing it with friends.
• 1:45
  SPEAKER_00: So uh thank you all so much for listening.
• 1:49
  SPEAKER_00: Now, to get into the episode for today for knee extension, this is something that gets missed a lot.
• 1:57
  SPEAKER_00: So I see patients who come in all the time and they might be four months out of surgery, they might be two years out of surgery, five years out of surgery, and they never got their range of motion back.
• 2:11
  SPEAKER_00: Now, the bending is one piece that is a whole topic in and of itself, but in general, the umbrella of range of motion is important, and it's one of the things that I talked about in the last episode of the quiet knee.
• 2:25
  SPEAKER_00: So it's one of the four main components.
• 2:29
  SPEAKER_00: But today we're specifically talking about knee extension, which has much more implications in terms of getting your knee back to full function and ACL rehab and recovery.
• 2:41
  SPEAKER_00: And that's what I want to focus on today.
• 2:45
  SPEAKER_00: So, what is knee extension?
• 2:47
  SPEAKER_00: So, we primarily think of the knee being able to flex, which is bending the knee, or extend, which is straightening the knee.
• 2:55
  SPEAKER_00: There is some rotation at your knee joint, but it's very minimal.
• 2:58
  SPEAKER_00: It's still important, but the main things that we're always trying to get after, especially after an ACL injury, is getting the flexion and extension back.
• 3:07
  SPEAKER_00: So, what I want you to do is take your leg and I want you to straighten out your leg.
• 3:14
  SPEAKER_00: So you can imagine pushing the back of your knee towards the ground, uh, trying to tighten up your quad muscle or the thigh muscle that's in the front.
• 3:23
  SPEAKER_00: And I want you to just kind of feel how that is.
• 3:26
  SPEAKER_00: Now, if you have an ACL side, I want you to take that knee and I want you to straighten that one out and try and feel how the quad feels there.
• 3:35
  SPEAKER_00: Does it feel even?
• 3:37
  SPEAKER_00: And if it does, then great.
• 3:39
  SPEAKER_00: If it does not, then where are you feeling it?
• 3:42
  SPEAKER_00: And just kind of think about where you're at in the process.
• 3:45
  SPEAKER_00: This is all going to depend.
• 3:47
  SPEAKER_00: For me, with my athletes, the goal is within the first two to three weeks after an ACL injury, and especially after a surgery, we're trying to get this knee extension back to the uninjured side.
• 4:00
  SPEAKER_00: The same comparison.
• 4:02
  SPEAKER_00: So you might be wondering why is knee extension so freaking important?
• 4:06
  SPEAKER_00: I'll tell you why.
• 4:08
  SPEAKER_00: So, number one, that it can be linked to osteoarthritis.
• 4:12
  SPEAKER_00: So they have done studies where they have looked at loss of knee extension and range of motion at the knee joint after an ACL reconstruction can lead to an increased risk of osteoarthritis.
• 4:25
  SPEAKER_00: So, a lot of times, what I will see is that patients will come to me after they've been doing therapy somewhere else, and their physical therapist or trainer, whoever it is, says it's okay to get to zero degrees of knee extension.
• 4:39
  SPEAKER_00: That's pretty much a straight line at your knee joint.
• 4:43
  SPEAKER_00: And if you look at the normal presentation of a knee, typically there's some hyperextension where it kind of goes back a little bit by three to five degrees, and the research norms show this.
• 4:57
  SPEAKER_00: But what happens is that it can sometimes take too long, or maybe there's a rush to get to the next phase of more the fun stuff, if you will, and it can get left behind.
• 5:08
  SPEAKER_00: But that is a huge foundational piece, and they've seen that link to Neo A, even as little as deficits from the one side to the other of three to five degrees, and it's even worse if you go above five degrees.
• 5:23
  SPEAKER_00: Um, next is the joint mechanics.
• 5:25
  SPEAKER_00: So the way that the joints interact with each other, we call that arthrokinematics uh in the PT world.
• 5:32
  SPEAKER_00: So that's where your tibio femoral joint, so that's where your shin bone and your thigh bone connect to each other.
• 5:38
  SPEAKER_00: There can be mechanics that are messed up with that.
• 5:41
  SPEAKER_00: Uh also your patellofemoral joint, so that's where your kneecap interacts with your femur, which is your thigh bone.
• 5:48
  SPEAKER_00: So this is all like more of PT jargon, but these are things that are important because, as you can imagine, if the normal structure is not restored, then stress starts going to other places within the knee because it can't access that range of motion.
• 6:06
  SPEAKER_00: And this is something to just kind of caution as you move forward because if you're going with higher intensity exercises, that could lead to increased stress in other areas, such as maybe your kneecap or your patellofemoral joint, where people can get pain a lot of the times.
• 6:22
  SPEAKER_00: So, this is something just to consider as you're moving forward.
• 6:26
  SPEAKER_00: Uh, this can also place increased wear and tear towards your articular cartilage, which is the tissue that is in between these different joints that can uh absorb load and to transfer force and create cushion to reduce friction around these joints.
• 6:43
  SPEAKER_00: Now don't go freaking out.
• 6:45
  SPEAKER_00: This is just something to be aware of, and I think in clinical use, people will hear this all the time where their cartilage is completely gone or it's bone on bone.
• 6:54
  SPEAKER_00: Don't worry about all that.
• 6:55
  SPEAKER_00: It's just something more to kind of keep front in mind and in the importance of working on your knee extension.
• 7:01
  SPEAKER_00: Next up is your screw home mechanism.
• 7:04
  SPEAKER_00: So this is something that is very technical, but I think it's very important and can get missed.
• 7:11
  SPEAKER_00: It goes back to how the joints move together.
• 7:14
  SPEAKER_00: But when you go to straighten your knee, there is a slight rotation depending on the position at that knee joint, and we call that the screw home mechanism.
• 7:22
  SPEAKER_00: And this can be something that can get missed a lot as well.
• 7:26
  SPEAKER_00: So if you can restore the normal joint mechanics, then the screw home mechanism can allow you to get into that end range knee extension, we call that terminal knee extension, and be able to activate your quad and access that range.
• 7:41
  SPEAKER_00: Alright, so now on to a little bit more of a practical sense, if you will.
• 7:45
  SPEAKER_00: So the quadriceps activation itself is best whenever we're at full terminal knee extension.
• 7:52
  SPEAKER_00: And that's gonna allow us to also fulfill maximal strength within the quadriceps as well.
• 7:58
  SPEAKER_00: So imagine this.
• 7:59
  SPEAKER_00: So you're gonna take your elbow, and I want you to straighten it out.
• 8:02
  SPEAKER_00: Like you're gonna uh extend that elbow, straighten it out, feel the back of your tricep, feel how hard it is.
• 8:10
  SPEAKER_00: And then now what I want you to do is bend your elbow just slightly and then try to engage it again.
• 8:16
  SPEAKER_00: So don't straighten it out, just keep it slightly bent.
• 8:18
  SPEAKER_00: Which one feels more contracted and activated and stronger?
• 8:23
  SPEAKER_00: It's the one with the arm straight.
• 8:25
  SPEAKER_00: And you can almost think is your elbow having a very similar function as your knee.
• 8:32
  SPEAKER_00: They work the same, they have a hinge, there's a little bit of a rot more rotational component at your elbow.
• 8:38
  SPEAKER_00: But the main thing that I want you to know here is that it works very similar, your tricep to your quadricep.
• 8:45
  SPEAKER_00: And if you don't have that end range for your tricep and your elbow, then you're not going to be able to access that full contraction, same thing as your knee, which is very important.
• 8:57
  SPEAKER_00: So you can use this as another practical example of let's say you're doing a push-up and you can't just hang out in that straight plank position, and you have to have that just bent elbow the entire time.
• 9:10
  SPEAKER_00: One is that your tricep is going to get very fatigued because it's gonna be constantly on all the time, anytime you're in that position.
• 9:18
  SPEAKER_00: Um, that's why we can hang out in plank positions more when the elbow is straight versus bent.
• 9:23
  SPEAKER_00: Uh so same thing with our knee here.
• 9:26
  SPEAKER_00: If I want you to think about if you can't get that normal knee extension, then anytime that you are walking or up on your feet, your quad and your hamstrings are going to be on most of the time.
• 9:37
  SPEAKER_00: So they're not gonna really get much of a chance to relax.
• 9:41
  SPEAKER_00: And this also leads to just a funky gait.
• 9:45
  SPEAKER_00: So you got this like really weird walk going where it's almost like a little bit of a hobble, or you might swing your foot around, which is very common with people who don't get their knee extension back.
• 9:56
  SPEAKER_00: So it alters your gait mechanics as well with this process.
• 10:00
  SPEAKER_00: So these are all the things which are a lot for why knee extension is important, and there's this isn't exhaustive, but these are some of the most important pieces that go into this.
• 10:14
  SPEAKER_00: Now, let's talk about the reasons why it might be hard to get that knee extension.
• 10:20
  SPEAKER_00: I just talked to you about the importance of it.
• 10:23
  SPEAKER_00: Now I want you to understand maybe some of the reasoning behind it, and now all of this to say this is purely educational, I don't want you to be making your own diagnosis.
• 10:33
  SPEAKER_00: This is something where having a physical therapist or you know a medical professional to help you along with this is very important.
• 10:41
  SPEAKER_00: But I do want to discuss some of the potential reasons behind this, so let's get into it.
• 10:46
  SPEAKER_00: Number one is pain.
• 10:48
  SPEAKER_00: Whenever you have an injury or whenever you have surgery, there is pain associated.
• 10:54
  SPEAKER_00: So that pain can be restricting to be able to get your knee straight.
• 10:58
  SPEAKER_00: There has been trauma to the knee, whether that is drilling holes or putting a graft in or just tearing the ACL itself, it is trauma to the knee.
• 11:08
  SPEAKER_00: So pain will be associated, and that might be one of the reasons why it's hard to get that knee extension back.
• 11:15
  SPEAKER_00: Swelling might be another reason why the joint itself has a lot of fluid or fusion in it, so this can really impact the way that the joints interact with each other, but then also it's just really swollen, so it could be difficult for those joints to approximate or to get into that terminal knee extension as they need to.
• 11:37
  SPEAKER_00: So swelling is definitely a huge culprit, and anyone who has had this injury is very familiar with swelling, and it is the bane of all PTs existence and people with ACLs because it can come and go, it'll show up whenever it wants, and sometimes without even any reason at all.
• 11:55
  SPEAKER_00: But especially early in this process, you will see swelling.
• 11:58
  SPEAKER_00: So that's one of the things to navigate.
• 12:01
  SPEAKER_00: Uh, quad inhibition.
• 12:03
  SPEAKER_00: So you will hear the term artogenic muscle inhibition.
• 12:08
  SPEAKER_00: So that is a term that can be used where the quad itself will not activate as well, and there are many different theories behind it, and we're not going to dive into those specifically, but it can be very difficult to turn on the quad, whether it's from the surgery itself, whether it's from the brain, whether it's from certain uh nerve type uh blocks that are used, which is the next point.
• 12:32
  SPEAKER_00: But the the nerve blocks that they'll use is to help to desensitize, so they'll use an adductor one, which is part of like the groin area, uh, and then there's one that'll be used that is your femoral nerve.
• 12:46
  SPEAKER_00: Um, I when I got mine, I got femoral nerve blocks in both of mine, and so that can impact maybe the motor or the ability to contract your quad muscle.
• 12:58
  SPEAKER_00: So that is just another thing to consider.
• 13:00
  SPEAKER_00: And then a cyclops lesion.
• 13:02
  SPEAKER_00: So this one can get missed a lot, um, and it's in a smaller percentage, but cyclops lesion, we're not exactly sure where this comes from.
• 13:12
  SPEAKER_00: Sometimes we think it can come from the old stump of the ACL that might not have been uh cut out, or it could be from uh potentially some of the tunnel drilling that happens.
• 13:23
  SPEAKER_00: And what it is is almost like the scar tissue that sets up, and uh it can impact the way that the knee can extend and flex.
• 13:32
  SPEAKER_00: And what people will see a lot of times is like some anterior knee pain, and they'll also uh not really be able to make any progress in their knee extension.
• 13:42
  SPEAKER_00: So we'll have to do an episode completely on that.
• 13:45
  SPEAKER_00: But cyclops lesion is just something to be aware of.
• 13:48
  SPEAKER_00: Uh, fear is one of these that I think can get missed.
• 13:53
  SPEAKER_00: Just the thought of trying to contract something and maybe thinking like something's going to tear.
• 13:59
  SPEAKER_00: They took a tendon from your patellar tendon or maybe quad tendon, and you're worried if you try to straighten your leg, something might happen, right?
• 14:07
  SPEAKER_00: And I remember when I had my ACL surgery that I was a little worried like if something was gonna kind of go wrong, whether the graph will come out, or you know, I did something to my hamstring or my quad.
• 14:19
  SPEAKER_00: So it's it's fair to feel that, but just be sure and know that you're okay with this, and that the fear is normal, and that the pain and the swelling, all those things are going to limit you just because of the way this process is.
• 14:35
  SPEAKER_00: So just be aware of that.
• 14:37
  SPEAKER_00: And one last thing uh that I think is important to note here is a potential bone bruise.
• 14:43
  SPEAKER_00: So when you have your ACL injury, maybe there was a bone bruise in there, and it's something that might be necessary to delay surgery because with a bone bruise, there's going to be more healing that is needed.
• 14:57
  SPEAKER_00: Uh you'll see more pain and inflammation and swelling.
• 15:01
  SPEAKER_00: So it's just something to note with this process.
• 15:03
  SPEAKER_00: Maybe surgery needs to be delayed because it can really influence how the joint is moving, of getting that extension and flexion back, getting your quad going.
• 15:13
  SPEAKER_00: And if you put it off, maybe, then you might have less complications when you actually do have the surgery if you choose to do so.
• 15:21
  SPEAKER_00: And that would be something just to consider.
• 15:24
  SPEAKER_00: Um, not everyone gets a bone bruise, but it does happen depending on the way that the ACL is injured.
• 15:30
  SPEAKER_00: So just think about that as uh you're you're thinking about your knee extension, and maybe there's a lot of joint swelling and pain.
• 15:37
  SPEAKER_00: And the other areas to look at with this is what is your kneecap or your patella, like how is it moving, the mobility of it?
• 15:47
  SPEAKER_00: How is your femur and your tibia?
• 15:50
  SPEAKER_00: That is your shin bone and your thigh bone, how are those two interacting with each other?
• 15:56
  SPEAKER_00: Uh, soft tissue restrictions, so we have our hamstrings and our calves at the back of the knee, along with other muscles, and then you have your quads.
• 16:04
  SPEAKER_00: So all of these soft tissue is what we call it, are all surrounding the joint, and that is something important to know because maybe there's a contracture uh at your hamstring, maybe there's something where it's really tightened up to where it's really limiting that last few degrees of extension.
• 16:22
  SPEAKER_00: So something else to consider, and then thinking about where the graft side is.
• 16:27
  SPEAKER_00: So if you have a patella tendon graft, then maybe it's restricting that kneecap to be able to move because there's some scar tissue, or maybe the patella mobility is not very good.
• 16:40
  SPEAKER_00: So these are things that are important, but I do not want you to go off and stress about 2,000 different things that might be going on.
• 16:51
  SPEAKER_00: I know that this can be a lot of information, but I just wanted to be informative, to be able to know, okay, there are different components of why it is so important to get your knee extension back, and also maybe some contributing reasons as to why it's happening that doesn't get explored enough.
• 17:08
  SPEAKER_00: And this is where I think it is important to work with someone who knows about this, who knows about this injury, who knows about the knee, who knows how to uh be able to assess for some of these things.
• 17:20
  SPEAKER_00: And one of the things that I want to make sure I leave you with is learning, okay, what is it that I need to get back to?
• 17:28
  SPEAKER_00: One is if your other knee is uninjured, then that is going to be your baseline.
• 17:33
  SPEAKER_00: You want to get it to the same as the uninjured side.
• 17:37
  SPEAKER_00: That is the baseline of knee extension that we're looking for.
• 17:40
  SPEAKER_00: Um, and if that side has been injured, then you want to try and just make sure that you can maximize as much knee extension, which for most people, typically it's around five degrees of hyperextension, so going right past zero degrees, and then working towards being able to contract your quad really well.
• 17:58
  SPEAKER_00: So these are all things that are important.
• 18:00
  SPEAKER_00: This podcast episode is not necessarily focused on just different techniques and things like that, because this is also just going to vary so much individual to individual, which is why I think it is very important to have a coach or a physical therapist, someone that you trust with this to make sure that you can get there and get the results that you want.
• 18:22
  SPEAKER_00: So make sure that you are focusing on knee extension as early as possible, get the range back within the first two to three weeks, and if not, keep working on it.
• 18:33
  SPEAKER_00: Um, make sure that you can tackle these different reasons and making sure that you keep at the forefront why it is important to get this back and not rush too quick into the next phase of your ACL rehab.
• 18:47
  SPEAKER_00: Cool, capiche, awesome.
• 18:50
  SPEAKER_00: Well, that's it for today, guys.
• 18:52
  SPEAKER_00: I know this was a lot on knee extension, 1920 whole minutes on knee extension.
• 18:57
  SPEAKER_00: You are welcome.
• 18:59
  SPEAKER_00: Appreciate you guys as always, and thank you so much for listening.
• 19:03
  SPEAKER_00: This is your host, Robbie Patel.
• 19:05
  SPEAKER_00: Sign it off.