Latest / The ACL Athlete Podcast / 096 | Pain with Kneeling in ACL Rehab

Transcript

096 | Pain with Kneeling in ACL Rehab · 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 ACL, 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.
• 1:03
  SPEAKER_00: What is up guys?
• 1:05
  SPEAKER_00: So today we are coming off of Thanksgiving here in the States.
• 1:09
  SPEAKER_00: It was nice to just take a second to just relax and breathe and to disconnect a little bit.
• 1:15
  SPEAKER_00: So I hope that you guys who were celebrating also had time to do that.
• 1:19
  SPEAKER_00: If you are not from the States and did not celebrate Thanksgiving, I hope that you just had a good weekend.
• 1:25
  SPEAKER_00: And for any of the new listeners here, welcome.
• 1:28
  SPEAKER_00: Today we are diving into pain with kneeling and ACL rehab.
• 1:34
  SPEAKER_00: This is a question I get so much, and it's probably one of those things where if you're listening to this episode, you're probably dealing with it and you're probably wondering, is this common for ACLers?
• 1:48
  SPEAKER_00: And I'm here to tell you it's very, very, very common for ACLers.
• 1:53
  SPEAKER_00: And it's a common question we get.
• 1:55
  SPEAKER_00: And today I want to try and tackle this as best as we can.
• 1:58
  SPEAKER_00: And if you're an ACL or listening to this, you know what I'm talking about.
• 2:02
  SPEAKER_00: If you're a post-op and you do that first time where you try to put the knee down and you're putting pressure on it, that kneeling sensation and feeling, people have different reactions to it, different feelings.
• 2:15
  SPEAKER_00: And so today we're going to talk about some of the factors related to that and the different experiences.
• 2:20
  SPEAKER_00: And one of the things to consider in this will be how close to post op you are.
• 2:24
  SPEAKER_00: It's going to be much, much more sensitive post-op, which makes sense, right?
• 2:29
  SPEAKER_00: You've had incisions done, you've had the ACL reconstruction done, things like some of the sensory superficial nerves were potentially impacted, a possible graph was taken, which we'll dive into here in a second.
• 2:41
  SPEAKER_00: The sensitivity typically improves as time goes on, but the question is, how much?
• 2:48
  SPEAKER_00: Well, that really depends.
• 2:51
  SPEAKER_00: And I know you guys hate that question, but is very applicable to this one.
• 2:55
  SPEAKER_00: But I'm gonna hopefully shed some light on this so that way you can really get the best answer here for what we know.
• 3:03
  SPEAKER_00: And the best answer really here is it is just going to really depend on your situation.
• 3:09
  SPEAKER_00: So why does this typically happen?
• 3:11
  SPEAKER_00: Why do we get pain with kneeling in your ACL rehab?
• 3:15
  SPEAKER_00: So it just mentioned how close to post op you are.
• 3:18
  SPEAKER_00: There's gonna be more sensitivity there the closer to post op.
• 3:21
  SPEAKER_00: What was done in the procedure?
• 3:24
  SPEAKER_00: So think about this for a second.
• 3:26
  SPEAKER_00: What all did they do?
• 3:27
  SPEAKER_00: There were likely some nerves that were impacted in this, sensory nerves to be specific.
• 3:33
  SPEAKER_00: And if you listen to the previous podcast episodes, episode 93 and 94, where we talked about numbness and specifically that infrapetellar branch of the saphenus nerve.
• 3:44
  SPEAKER_00: That is a nerve that gets impacted during ACL surgery.
• 3:47
  SPEAKER_00: And while we talked about numbness in those episodes, this goes hand in hand with also pain because sensory nerves provide information, it provides the input as I had mentioned.
• 3:58
  SPEAKER_00: Motor nerves are the output, they create the function.
• 4:02
  SPEAKER_00: So sensory nerves, and that's what the infrapentillar branch of the sapphis nerve is.
• 4:07
  SPEAKER_00: It's a sensory nerve, or it creates afferent feedback for us, and it provides senses for touch, pain, temperature, vibrations, and gives our brain info about the environment around us.
• 4:20
  SPEAKER_00: So this includes kneeling and feeling the pressure of kneeling and how that feels on your body.
• 4:25
  SPEAKER_00: It's a byproduct of the surgery just naturally for the sensory nerve and that specific nerve to be impacted.
• 4:32
  SPEAKER_00: Luckily, in majority of cases, this nerve being affected doesn't really impact your physical function, your ability to extend your knee.
• 4:42
  SPEAKER_00: Sure, you might have some discomfort in that pain, but it's typically not going to limit you from being able to extend the knee in most cases, since it's not a motor nerve, but it is going to affect the sensation and the things that you feel.
• 4:56
  SPEAKER_00: And the other thing that I mentioned in this podcast is nerve regeneration is a very slow game.
• 5:02
  SPEAKER_00: We use the analogy of a turtle sprinting, which is not very fast.
• 5:07
  SPEAKER_00: And so this is the thing that I want you to think about here is that if we're impacted based on the sensation, if we're impacted based on the nerve, and if that nerve had might have been cut, or maybe it was stretched, or some sort of impact to that specific nerve or the surrounding nerves, then that's going to impact the growth and the healing, therefore impacting your sensory input if that nerve is not doing its job.
• 5:32
  SPEAKER_00: And so here, what I want to make sure we highlight is that physiology shows us, and based on the research, that nerves grow super slow, one to four millimeters per day, and sensory nerves tend to be better than motor, and it could take months to years for that to really regrow.
• 5:49
  SPEAKER_00: And that's if they find each other.
• 5:51
  SPEAKER_00: And even then, it might produce a different sensation from when the sensory input does come back.
• 5:58
  SPEAKER_00: So instead of maybe a palm size area that's impacted, maybe it's a little bit more specific.
• 6:04
  SPEAKER_00: And again, this is gonna be different ACL to ACLer, but this is all a part of the nerve, right?
• 6:10
  SPEAKER_00: That's an impact to this.
• 6:12
  SPEAKER_00: Now, let's talk about what the research says on this.
• 6:15
  SPEAKER_00: There isn't very specific research on the why and all these different factors related to kneeling pain.
• 6:22
  SPEAKER_00: They have studied different techniques and procedures and especially the differences in graph types.
• 6:27
  SPEAKER_00: And so Riaz in 2015 looked at kneeling with patients, and they saw that 71 patients were operated on, they followed up with these people in three and a half years, and the average age of these patients were around 30.
• 6:41
  SPEAKER_00: 22 of these patients had anterior knee pain on kneeling.
• 6:45
  SPEAKER_00: Then there was 23 that had paresthesias with the anterior knee, and that basically means the numbness.
• 6:52
  SPEAKER_00: And so when you're looking at 65 patients and they looked at their ability to kneel, they looked at basically how long they could.
• 7:00
  SPEAKER_00: 36 of them were able to kneel for unrestricted periods of time, nine of them for five to fifteen minutes, 15 could kneel for one to five minutes, and five of them could only do less than one minute.
• 7:14
  SPEAKER_00: And then there were six that were unable to kneel overall.
• 7:18
  SPEAKER_00: So this gives you a little bit of an idea of the range of what people can feel, and this is three and a half years after.
• 7:26
  SPEAKER_00: So this is just some information of like, okay, why is it that I'm feeling this?
• 7:30
  SPEAKER_00: Why hasn't it really improved even though I'm six, twelve months, or even three and a half years out from this?
• 7:37
  SPEAKER_00: And this leads me to my next point, which is the graft that is used.
• 7:41
  SPEAKER_00: So usually there's allograft, which is taken from a cadaver, and there's autograph that's taken from yourself.
• 7:47
  SPEAKER_00: The three autographs, either patella tendon, quad tendon, or hamstring tendons, are taken from your own self.
• 7:55
  SPEAKER_00: The patella tendon, historically, with research and anecdotally working with tons of ACLers at this point, tend to have more kneeling and patellar pain.
• 8:04
  SPEAKER_00: It's just natural because why?
• 8:07
  SPEAKER_00: The graft is taken from that point where that contact is going to be made.
• 8:11
  SPEAKER_00: And when you look at the research, Corey and Spindler did some research on comparing kneeling and pressure.
• 8:18
  SPEAKER_00: And 31% of individuals in these studies with a patellar graph experienced pain with kneeling following ACL surgery.
• 8:26
  SPEAKER_00: Whereas when they compared it to the hamstring graph, only 6% of those felt pain with kneeling.
• 8:31
  SPEAKER_00: So this is just something that you want to be able to kind of factor in of like, okay, the graph type does matter.
• 8:37
  SPEAKER_00: The research does show that.
• 8:40
  SPEAKER_00: Now let's talk about some of the specifics here.
• 8:42
  SPEAKER_00: Just think about like what's being taken, especially with the patellar tendon.
• 8:46
  SPEAKER_00: One is that there is a scar and incision that is done at the front of the knee.
• 8:51
  SPEAKER_00: There's an impact there.
• 8:52
  SPEAKER_00: The incision is cutting through the skin, which is going to impact the sensory input to that area.
• 8:58
  SPEAKER_00: And then when you think about the next layer, they're going to take part of your patella tendon.
• 9:02
  SPEAKER_00: That's the typically the middle part of your patella tendon, and they're going to cut that.
• 9:07
  SPEAKER_00: So that's impact from a sensory piece there.
• 9:11
  SPEAKER_00: Part of the bone on the top part of that patellar tendon, or actually at the very base of your patella at the bottom, is going to be taken.
• 9:19
  SPEAKER_00: They're going to cut a small little piece of that bone.
• 9:21
  SPEAKER_00: And then the same thing is going to be done at your tibual tuberosity, which is where the other side of that patellar tendon is anchored.
• 9:28
  SPEAKER_00: They're going to cut both ends, and usually there's a bone at both ends of the patellar tendon, and that is going to be impacted as well.
• 9:35
  SPEAKER_00: So now we're taking away from bone, we're taking away from tendon, we're taking away from the skin.
• 9:40
  SPEAKER_00: We're also taking away from the sensory nerve that was potentially impacted as well.
• 9:46
  SPEAKER_00: So these are all things that are just part of the procedure, and it's basically weighing the risk reward of I want a functional ACL that is stable, that can let me do my things, and taking a graft from a site that is really good.
• 10:00
  SPEAKER_00: I'm actually a fan of the patellar tendon.
• 10:03
  SPEAKER_00: It's a great graft, but this is a little bit of the trade-off with a good graft and getting it from this spot and the ACL surgery versus the sensory changes that happen.
• 10:13
  SPEAKER_00: It's just a byproduct of doing the surgery.
• 10:17
  SPEAKER_00: And then there's a process of how does it all heal and how does your body interpret that?
• 10:23
  SPEAKER_00: This isn't to deter you from this graft.
• 10:25
  SPEAKER_00: And as I mentioned, I actually like the graft, but it does come with that territory, and I'm hoping that this surgical technique will improve in the years to come so people can improve on that anterior knee pain or that kneeling discomfort.
• 10:41
  SPEAKER_00: If we were to line up a hundred different ACLers, different ages, different types of body types, different histories, and if we're a line them all up, most of them would have some sort of funky numbness or kneeling discomfort.
• 10:55
  SPEAKER_00: That's a pretty common thing that we see across the board.
• 10:58
  SPEAKER_00: And this would be something that is more apparent with people who get patellar tendon graphs because that is going to be taken from that area where you kneel.
• 11:08
  SPEAKER_00: And so that's where you would potentially see more of that anterior knee discomfort or that numbness and the kneeling pain.
• 11:15
  SPEAKER_00: And you guys know I'm always honest with you in this process, and that's what's so important is to manage expectations.
• 11:22
  SPEAKER_00: And this podcast is focused on being real with you versus giving you what you want to hear or sugarcoating thing.
• 11:29
  SPEAKER_00: And that's where this is really important is that I'll get this question a lot of like, hey, I have this kneeling pain or this discomfort, and we'll talk through with athletes or even people through Instagram or email or whatever it is that they're reaching out, and we talk through this whole point of how it is a difficult question to answer.
• 11:47
  SPEAKER_00: And I wish we had the answer, but we don't.
• 11:51
  SPEAKER_00: And these are the factors that are playing into it.
• 11:53
  SPEAKER_00: The other piece of this, too, is also how your rehab goes, how you rebuild the tendon site, how you do all these different things, which we're actually about to talk about here next, the things that will help in this process and the things that you can do to best optimize for getting this kneeling pain to improve.
• 12:13
  SPEAKER_00: The first thing is going to be desensitizing.
• 12:16
  SPEAKER_00: So you want to make sure that the scar tissue around the actual incision is moving well, it's gliding well, it's moving like your other skin, and it's not tacked down and it's like really rough.
• 12:28
  SPEAKER_00: You want to make sure you work on that early in the process once your wounds are healed and you can start massaging into those areas and different techniques.
• 12:36
  SPEAKER_00: But you want to make sure that stuff moves well.
• 12:38
  SPEAKER_00: The same thing with the patellar tendon, especially if you get that graft, making sure that your patella is mobilized and moving well.
• 12:46
  SPEAKER_00: This can all help with making sure your body starts to recognize these things as normal.
• 12:51
  SPEAKER_00: And then even different textures like pressure or light scratching, things like that, where you get input, can help to build afferent feedback to the brain and allow your body to start to interpret those as hopefully not sensitive type positions or pressures.
• 13:09
  SPEAKER_00: The other thing here is like, okay, so maybe you do have that sensitivity or that kneeling pain.
• 13:14
  SPEAKER_00: What can you do to still get to those positions?
• 13:18
  SPEAKER_00: Let's say you do yoga or you're trying to do a half kneeling type exercise or whatever that might be, maybe playing with your kids on the ground.
• 13:26
  SPEAKER_00: Softer surfaces are going to be key.
• 13:28
  SPEAKER_00: So being able to have a yoga mat or a pad, a pillow, things of that nature, hopefully will help with the pressure compared to the ground, especially something like a hard ground or hardwood floor, right?
• 13:40
  SPEAKER_00: So having something soft underneath your knee where the kneeling pain is can help to maybe desensitize or just create a little bit of softness there so it's less firm pressure.
• 13:51
  SPEAKER_00: Time is a big one.
• 13:52
  SPEAKER_00: So time further away from the surgery, the more healing potential your body has, especially if it's also a nerve growth related.
• 14:00
  SPEAKER_00: The more time you got, the more healing capabilities you have.
• 14:04
  SPEAKER_00: And I mentioned earlier it's also a part of this process.
• 14:08
  SPEAKER_00: And if anyone can put a specific timetable on it, I'd question their understanding of this process because many of you listening might say you don't feel it at all.
• 14:18
  SPEAKER_00: Maybe you felt it up until the six-week mark or the three-month mark and it went away.
• 14:23
  SPEAKER_00: Maybe you're at six or nine or twelve months and it's gone now, or maybe your years out and it's still there.
• 14:31
  SPEAKER_00: All with varying levels of how it feels and the feeling of it in general.
• 14:36
  SPEAKER_00: So just know that you are not crazy.
• 14:38
  SPEAKER_00: It's completely normal.
• 14:40
  SPEAKER_00: When in doubt, always ask your healthcare professional, your physical therapist, your surgeon, especially if this is something that is a limiter.
• 14:50
  SPEAKER_00: And this is what leads me to my last point and question here.
• 14:53
  SPEAKER_00: The question I'll always ask to my athletes is this kneeling pain limiting you from our work together?
• 14:59
  SPEAKER_00: That's one, and then making sure that is it getting in your way of getting to your goals?
• 15:05
  SPEAKER_00: That's two.
• 15:06
  SPEAKER_00: So these are the two questions that I want you to be able to ask yourself, and this is what I ask them.
• 15:12
  SPEAKER_00: And if it's not limiting them and it's allowing us to move towards their goals, then we're good.
• 15:17
  SPEAKER_00: If it is limiting them and it is limiting us from getting towards their goals, then we need to talk through strategies of how we can best navigate this, especially if it is a very big limiter.
• 15:28
  SPEAKER_00: But just know that this is something that we can only do so much with the body, giving it time to heal, giving it the right environment, giving it the right textures and surfaces.
• 15:38
  SPEAKER_00: And these are gonna be what's gonna be key in order to work through this and make sure that you understand where this is coming from, why you might be dealing with it further down the road than you think.
• 15:50
  SPEAKER_00: So if you're going through this now, now with this information, I encourage you to ask yourself the same questions.
• 15:58
  SPEAKER_00: Is this kneeling pain limiting you from your work and your rehab?
• 16:03
  SPEAKER_00: And is it getting in the way of you getting to your goals?
• 16:06
  SPEAKER_00: Those are gonna be the questions that you need to ask because it's gonna be a part of the process.
• 16:11
  SPEAKER_00: It's just working through and seeing, okay, can we still move the needle forward and can we also work to improve this?
• 16:18
  SPEAKER_00: And then just also seeing how does this play out over time.
• 16:21
  SPEAKER_00: Again, when in doubt, ask the person who's guiding you.
• 16:25
  SPEAKER_00: But just know if you're sitting here, I've got kneeling pain, you might be six months out, you might be five years out.
• 16:32
  SPEAKER_00: It's more normal than you think.
• 16:34
  SPEAKER_00: So I'm here to let you know I've got some kneeling numbness on my right side.
• 16:38
  SPEAKER_00: I do not have any pain when I kneel, and that's I would attribute mostly to not having a patellograft.
• 16:46
  SPEAKER_00: That's the main thing.
• 16:48
  SPEAKER_00: Work through all these like problems that I had early on, mobilize the tissue around it, or maybe I just got lucky with my two ACLs, but plenty of ACLers I know who are doing everything they can, and they're a year out, they are maybe six months out and they're still dealing with it.
• 17:04
  SPEAKER_00: So just know that you're not alone.
• 17:07
  SPEAKER_00: All right, team, that's gonna be it for today.
• 17:09
  SPEAKER_00: Thank you so much for listening.
• 17:11
  SPEAKER_00: This is your host, Robbie Patel, signing off.