Tag Archive for: ACL

The Week in Research Review, etc 8-5-18

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The Week in Research Review, etc 8-5-18 we discuss a wide variety of topics including:

  • Long-term disability if weak during adolescence
  • Using heat during rehabilitation
  • OKC vs CKC exercises after an ACL
  • Live look at an Achilles rupture (with sound too!)
  • A fun look at the different types of PT’s
  • Congrats to all of the newly licensed PT’s!

Muscular weakness in adolescence is associated with disability 30 years later: a population-based cohort study of 1.2 million Swedish men. Henriksson et al BJSM June 2018.

Conclusion: There was a strong association between muscular weakness and disability. A combination of muscular weakness and low aerobic fitness was an especially important risk factor for disability. This adds weight to call for muscular strength and fitness-enhancing exercise for adolescents in all BMI categories.

This study out of Sweden looked at the associations of muscular strength in adolescence with later disability pension.

A total of 1 212 503 adolescent males aged 16–19 years, recruited from the Swedish military conscription register between 1969 and 1994.

Moral of the story: exercise as an adolescent may help to reduce issues later in life, including the potential for disability.

Taking it 1 step further… why is physical education being cut out of school requirements when studies like this show the potential negative effects of inactivity?!

Turning Up the Heat: An Evaluation of the Evidence for Heating to Promote Exercise Recovery, Muscle Rehabilitation, and Adaptation McGorm et al Sports Medicine June 2018.

Key Points: Animal and human trials have shown that various forms of heating can be used in conjunction with exercise or stress to enhance recovery, adaptation and limit muscle atrophy.

Heating muscle activates protective mechanisms, reduces oxidative stress and inflammation, and stimulates genes and proteins involved in muscle hypertrophy.

Further studies highlighting the differences between various heating modalities will help inform athletes and coaches on the best heating practices for specific situations.

This article has a ton of great information that I highly recommend any PT, strength coach, athletic trainer or massage therapist.

It is a review of the literature and there are still many questions to be answered so, as always, take with a grain of salt.

I am a fan of heating before treatment…I do it daily with 99% of the clients that I see and they love it…so that says something.

What do you think? Do you like to heat your clients up before treatment or before a workout? Tag a friend that may benefit from this post! Thanks, guys!

The Effect of Open- Versus Closed-Kinetic-Chain Exercises on Anterior Tibial Laxity, Strength, and Function Following Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis Perriman et al JOSPT July 2018 Level 1a

FINDINGS: There was no significant difference in anterior tibial laxity, strength, patient-reported function, or physical function with the early or late introduction of open-kinetic-chain exercises in those who have had anterior cruciate ligament reconstruction, when compared to closed-kinetic-chain exercises, at all follow-up time points.

They wanted to determine whether OKC quadriceps exercises result in differences in anterior laxity, when compared to CKC exercises, at any time point following ACLr.

Also, they wanted to determine whether there are differences in strength, function, quality of life, and adverse events with OKC quadriceps exercises when compared to CKC exercises at any time point.

Overall, calculated effect sizes showed a slight increased laxity in the OKC groups, particularly for the hamstrings graft. The⠀
pooled difference was not statistically significant (P>.05)

When considering all graft types, there was low- to moderate-quality evidence from 3 studies suggesting that there were no between-group differences in laxity at any time point when OKC exercises were introduced earlier than 6 weeks post ACLR, compared to CKC exercises.

There seemed to be a trend that showed early OKC knee extension was safer after a PTG than a hamstring autograft but protocols varied so data was inconsistent.

Of interest to me, they said “The early introduction of OKC quadriceps exercises did not appear to offer additional significant benefits in function and strength for the average patient post ACLR; therefore, this early introduction is questionable, especially in patients with a hamstring graft.

From Twitter’s @IrineuLoturco showing the moment this athlete ruptured their achilles tendon. Pretty impressive and you can see the eccentric loading of the tendon that caused the rupture. See his original post below…

A very impressive recording of the exact moment when an elite sprinter had an acute and complete rupture of the Achilles tendon. Pay attention to the “boom”.

[REPOST] If there was an ESPY for a post by a PT then @theperformancedoc would definitely get it for these videos! Great job and keep pumping out great content. Give him a follow if you haven’t already!

👇🏻
💥Different Types of Physical Therapists In the Real World💥 SWIPE 👉🏽 (Turn on 🔊) Sometimes we have trouble “turning it off” when we are outside of the clinic. Which one are you?! Tag, Comment, & Share with a Physical Therapist‼️
–
▪️
#ThePerformanceDoc #RehabWithTheDoc
#TeamMovement

Congrats to all of the newly licensed PT’s out there…Welcome to the profession!

My advice to you:

Stay humble and put the patient first, always

Keep learning and try to avoid complacency

The road will seem rough but it does get a little easier. Get experience…as much as you can. Each interaction with a patient is a snapshot to help guide your future interactions.

Put yourself in their shoes… give them the best experience as you would expect to receive if you were sitting on the plinth being asked questions.

Follow people on social media that help you to learn and keep an open mind. Don’t get pulled into 1 system. Take a little from each and package it nicely.

The research is often biased. Opinions come and go. Stay somewhere in the middle…remember the bell curve, always!

Each “system” has huge overlap despite their ‘trademarked’ proprietary information…they all involve motion and strengthening. That’s the key to PT- keep people moving and keep them stronger…or at least keep them positive and hopeful.

I recently wrote a blog post discussing the evolution of a PT. Take a look…the link is in my bio on Instagram.

These words are the basis of my practice. Take what you think is important and apply it to your practice. Good luck, now work on your dives!

A great week of content that I hope you found valuable and willing to share with your friends and colleagues! Thanks for reading!

The Week in Research Review, etc 7-29-18

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Last week was the 1st of my research review that summarized my social media posts from the previous week. It seemed to be well received so I figured I’d continue it. My goal is to help summarize some of the research that I found interesting and package it nicely for my readers.

Each photo contains a link back to a social media feed where you can see the conversation that ensued and maybe chime in…or just be a passive reader and see where the conversation went. You never know where the conversation may go on social media…so be ready! haha!

Socioeconomic Factors for Sports Specialization and Injury in Youth Athletes Jayanthi et al Sports Health Journal 2018.

This study looked at the effect of socioeconomic status (SES) on rates of sports specialization and injury among youth athletes.

They looked at injured athletes between the ages of 7 to 18 years that were recruited from 2 hospital-based sports medicine clinics. They compared these with uninjured athletes presenting for sports physicals at primary care clinics between 2010 and 2013.

They concluded that:
✅High-SES athletes reported more serious overuse injuries than low-SES athletes
✅More hours/wk playing organized sports
✅Higher ratio of weekly hours in organized sports to free play
✅Greater participation in individual sports

I applaud the authors for attempting to bring this very difficult collection of data into a formal research paper. I will say some of the statistics and standard deviations may not make the conclusions as powerful.

I do think this is a good paper to help educate our athletes on injury rates, especially in those that specialize in 1 sport.

What do you think? Tag a friend that may benefit from this article!

From #Twitter’s @retlouping that perfectly sums up what I’ve observed recently on social media with many PT’s.

For some reason, pain science has overtaken most diagnosis and treatment conversations.

It’s as if you get bullied into talking pain science and ignoring our clinical judgment and diagnosis skills. I understand there’s a constant tug-of-war between the biomechanical PT’s and the pain science PTs.

But as usual, the answer usually lies somewhere in between and both groups are correct. The biomechanics of an injury are often important as well as the language we use to explain these tissue biomechanics.

To my fellow clinicians, especially the newer grads and #dptstudent, remember this little cartoon for every future encounter.

Yeah, speak to people in non-threatening tones (in my world it’s just being respectful) but trust me, they WANT to hear what could be going wrong or what may be causing their pain.

Don’t blow off their symptoms and don’t go into depth about pain science because they won’t understand.

Trust me, the clinicians that try to do that often end up losing their patients in the long run.

I hear these stories day after day of people coming to me because the last PT either only talks to them or made them ONLY do strength exercises and it didn’t help their pain.

The PT didn’t listen to them and was so blinded by their pain science background that they ignored the person sitting right in front of them. Remember, the person sitting there will tell you what is going on and what treatment will most help them feel/move better.

Influence of Body Position on Shoulder and Trunk Muscle Activation During Resisted Isometric Shoulder External Rotation Krause et al Sports Health 2018.

The purpose of this study was to examine ER torque and electromyographic (EMG) activation of shoulder and trunk muscles while performing resisted isometric shoulder ER in 3 positions:
✔️Standing
✔️Side-lying
✔️Side plank

Using surface EMG and a hand-held dynamometer, the researchers tried to determine EMG activity of the:
✔️infraspinatus
✔️Posterior Deltoids
✔️Mid traps
✔️Multifidi
✔️External/internal obliques (dominant side)
✔️External/internal obliques (non-dominant side)

EMG values for the infraspinatus were greatest in the side plank position. In general, EMG values for the trunk muscles were also greatest in the side plank position.

✅Their Conclusions: If the purpose of a rehabilitation program is to strengthen the rotator cuff, in particular, the infraspinatus, the side plank is preferred over standing or side lying. If the goal is to simultaneously strengthen both the rotator cuff and trunk muscles, the side plank position again is preferred.

Makes sense but good to see the research and have concrete evidence to back up what we think actually goes on.

Tag a friend who may be interested in this research paper!

Reliability of heel-height measurement for documenting knee extension deficits. Schlegel et al AJSM 2002

Prone heel-height difference of 1cm equates to 1.2 degree difference in knee extension ROM.

Do you use this method to assess knee ROM? I still measure knee extension ROM is supine but find this method helpful as well.

I know my friend and colleague @wilk_kevin has measured this way for many years. i originally saw his use this technique at @ChampionSportsM

I don’t want people to confuse this with prone hangs for knee extension ROM. I am not a fan of that method as I’ve stated in the past.

This is a method to assess knee extension differences, particularly after an ACL reconstruction. I have gone back to using this method for some people that have subtle ROM differences side-to-side.

The patella position (on the plinth or off) did not matter in the study and thigh girth did not appear to make a difference.

I would recommend stabilizing the pelvis to prevent excess ROM from occurring at that region and to better isolate the knee joint.

Have you tried this method? Tag a friend who may benefit from using this ROM method…thanks!

Evidence-Based Best-Practice Guidelines for Preventing #ACL Injuries in Young Female Athletes: A Systematic Review and Meta-analysis Petushek et al AJSM 2018.

Injury prevention neuromuscular training (NMT) programs reduce the risk for anterior cruciate ligament (ACL) injury.

Eighteen studies were included in the meta-analyses, with a total of 27,231 participants, 347 sustaining an ACL injury.

The overall mean training amount was 57 sessions totaling 18.17 hours (roughly 24 minutes per session, 2.5 times per week).

They concluded:

✔️Interventions targeting middle school or high school–aged athletes reduced injury risk to a greater degree than did interventions for college or professional-aged athletes.

✔️Continued exposure to neuromuscular training throughout the sport season seems to enhance prophylactic effects of NMT.

✔️NMT interventions were effective for female basketball, and handball athletes and interventions including various athletes were potentially effective (eg, soccer, basketball, and volleyball).

✔️ Interventions included some form of implementer training (eg, instructional workshop, video, or brochure) on proper program implementation.

✔️Programs including more landing stabilization and lower body strength exercises during each session were most effective.

🤔Programs including balance, core-strengthening, stretching, or agility exercises were no more effective than programs that did not incorporate these components.

✔️ Specifically, programs that included more landing stabilization exercises (eg, drop landings, jump/hop and holds), hamstring strength (eg, Nordic hamstring), lunges, and heel-calf raises reduced the risk for ACL injury to a greater degree than did programs without these exercises.

✅ Wow, lots of great information here. Please share this with a friend or colleague who may benefit from knowing this information.

Hope that helped to catch you up on my posts from this week.

Do you like these weekly updates? Let me know if I should continue…love your feedback!

Thanks for reading!

The Week in Research Review, etc 7-22-18

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The Week in Research Review, etc 7-22-18

I’m trying out this new concept of publishing my social media posts into a nice package for a weekly delivery to my subscribers.

  1. Knee Case Study
  2. Contralateral ACL Strengthening
  3. Shoulder Static Stabilizers
  4. Weighted Ball Research
  5. Glute Activation


This kid came to me the other day with L knee swelling after sliding headfirst into 2nd base during a baseball game.⠀

Continued to play in the game and even pitched the next day, all without pain or loss of motion.⠀

As you can see from the video, he has a bunch of fluid in his knee, medial ecchymosis (bruising) but full pain-free ROM.

Ligamentous tests appear negative and he has absolutely no pain or stiffness with anything.

I took this video to show what appears to be a bursal sac disruption from the impact of his knee into the ground as he was sliding.

The mechanism fits the presentation and clinical exam.

I advised him to monitor his swelling, wear a knee sleeve and continue his activities per his tolerance.

He is going to touch base with me next week to make sure the fluid is dissipating (and not worsening) and he remains asymptomatic.

What do you think? Am I missing anything? What’s your diagnosis? Tag a friend who may be interested in this case.

Cross-education improves quadriceps strength recovery after ACL reconstruction: a randomized controlled trial. Harput et al Knee Surg Sports Traumatol Arthrosc. 2018

This study looked at a group of ACL reconstructed patients that were divided into 3 groups.

All 3 groups performed the same standardized ACL rehab, but one group was the control group that performed the standardized rehab only.

The other 2 groups did either 3x per week extra concentric knee extensions on their uninjured leg for 2 months (beginning at 1-month post-op through 3-months post-op) or additional eccentric knee extensions on their uninjured leg 3x per week for 2 months between months 1-3 post-op.
💪🏼
They found that the quads strength for the concentric group was 28% greater compared to the control group. 💪🏼
The eccentric group was 31% greater when compared to the control group.

Conclusion: Concentric and eccentric quadriceps strengthening of healthy limbs in early phases of ACL rehabilitation improved post-surgical quadriceps strength recovery of the reconstructed limb.

Pretty crazy stuff and one more reason to work on bilateral strengthening with most of our patients, especially when they’re post-op ACL reconstruction.

Do you work on bilateral strengthening? if not, why? If you do, what other studies have you seen that show similar results?
Tag a friend who may benefit from this study or let’s discuss in the comments section!

This picture shows a simplified view of the static stabilizers of the shoulder joint. I highly recommend reading a classic paper by Wilk et al 1997 JOSPT that talks about this and cites a paper from Bowen et al Clin Sports Med 1991 @wilk_kevin

When one is picturing these stabilizers, the superior glenohumeral ligament (SGHL) is most taut when the shoulder is externally rotated at 0 degrees of abduction.

As we progress to 45 degrees of GH abduction, we stress the middle glenohumeral ligament (MGHL) as we externally rotate the humerus.

Finally, at 90 degrees of GH abduction, we stress the inferior glenohumeral ligament (IGHL) as we externally rotate. More specifically, the anterior band of the IGHL.

As we internally rotate at 90 degrees of abduction, we stress the posterior band of the IGHL.

These concepts have rehab implications and should be kept in mind when we’re rehabbing people after an injury or surgery.

For example, if someone has an anterior Bankart lesion (front labral repair), then we need to progress them slowly into external rotation, especially at 45 and 90 degrees of abduction.

Another example would be a rotator cuff repair, like the supraspinatus. We would want to progress them slowly at lower degrees of abduction 0-45 degrees but maybe we can progress them a bit quicker at 90 degrees of abduction.

Hope these concepts make sense because they are very important to understand for many patients with shoulder injuries.

Does this make sense? Have you heard this info before? Tag a friend who may benefit from this post!

Effect of a 6-Week Weighted Baseball Throwing Program on Pitch Velocity, Pitching Arm Biomechanics, Passive Range of Motion, and Injury Rates. Reinold et al Sports Health Jul-Aug 2018. @mikereinold⠀

Our 1st of potentially 3 research articles looking at the effects of weighted balls on youth baseball pitchers.

High school baseball pitchers performed a 6-week weighted ball training program.

Players gradually ramped up over the 6 weeks to include kneeling, rocker, and run-and-gun throws with balls ranging from 2oz to 32 oz.

🤔After 6 weeks, the weighted ball group did increase velocity by 3.3%, 8% showed no change, and 12% demonstrated a decrease in pitch velocity. Also of note, 67% of the control group also showed an increase in pitch velocity.⠀

The weighted ball group had a 24% injury rate although half of the injuries occurred during the study, and the other half occurred the next season. There were no injuries observed in the control group during the study period or in the following season.

The weighted ball group showed almost a 5-degree increase in passive shoulder external rotation, also known biomechanically as the late cocking position or layback position.

There were no statistically significant differences between pre- and post-testing valgus stress or angular velocity in either group.

✅Our conclusion: Although weighted-ball training may increase pitch velocity, caution is warranted because of the notable increase in injuries and physical changes observed in this cohort.

Some great Glute 🍑thoughts buy the @theprehabguys. Check out their videos and content for some great ideas that you can add to your practice!⠀
👇🏼⠀
___________________________________________________________________⠀
Episode 705: “Hip Prep for Glute Activation”⠀
.⠀
Tag a friend looking for a glute🍑 killer!⠀
Hip prep is a series of 6 exercises I’ve adopted from my girlfriend @smenzz and her clinic @eliteorthosport. I use it with my patients to prime the glutes and lower body in general before getting into more dynamic and plyometric activities. I will make the statement right now: if done RIGHT, it’s an absolute glute killer & I promise you that you will feel your glutes!⠀
.⠀
I like these 6 exercises in particular for a variety of reasons.⠀
✅They challenge the glutes in all 3 planes of motion.⠀
✅They hit all types of muscle contractions: isometric, concentric, and eccentric⠀
✅They are performed upright in a functional position⠀
✅There is a variety of double leg, single leg, and split stance variations⠀
✅They train proper lower extremity alignment in a variety of hip and trunk flexed/neutral/extended positions⠀
.⠀
The 6 exercises are:⠀
1️⃣3 way clams: 5 per leg per position⠀
2️⃣Side steps: Alternating steps to the left and right starting with 1 step all the way to 5 steps⠀
3️⃣Monster Walks: 10 steps forward, 10 steps backwards⠀
4️⃣W’s: 10 steps to the left, 10 steps to the right⠀
5️⃣Squats: 10 squats⠀
6️⃣Single leg fire hydrants: 30s per side⠀
.⠀
💡Understand that you first need to teach these exercises in isolation first, before throwing someone all 6 at once⠀
.⠀
Have fun!⠀

Hope this helps you keep up to date and fulfill my goal of this website…simplify the literature and bring great content to you so you can apply it 1st thing Monday morning! Happy Reading! 👊🏼

Follow me on Social Media here:

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Quadriceps Stretching after Knee Surgery: A tweak to the technique

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Obtaining full knee flexion after a knee surgery or knee injury can be difficult for some. The transition from passive knee flexion in seated (my preferred) or supine (not preferred!) can be a challenge for the physical therapist, once they are starting to work on quadriceps stretching. This blog post serves to help modify the prone quadriceps stretching technique after a knee surgery. The goal is to better localize the stretch to the muscle and not cause further pain and discomfort to the patient.

In the past, I’ve talked about restoring knee extension after surgery, particularly after an ACL reconstruction. If you missed that blog post, you can read it here here and here. You might say I have a slight obsession with talking about ROM after surgeries.

For a common surgery like an ACL reconstruction, I often see people present to me without full ROM. That’s why I continue to discuss techniques that can help other clinicians and patients restore their ROM before it’s too late.

Why is full ROM important after knee surgery?

Well, we think there’s a pretty close link between long-term issues and not restoring knee ROM.

In Shelbourne’s article in AJSM 2012, he states that “abnormal knee flexion at early follow-up, abnormal knee extension at final follow-up, abnormal knee flexion at final follow-up, partial medial meniscectomy, and articular cartilage damage were significant factors related to the presence of osteoarthritis on radiographs.”

He also went on to say that you had a 2x increased risk of knee arthritis if you don’t get full ROM. This was similar to having had a meniscectomy surgery or articular cartilage loss.

For such a simple concept, we PT’s can really affect the long-term outcomes for our patients if we don’t get full knee ROM. So why are people still struggling years after their knee surgery? I don’t know… but it’s troubling and definitely avoidable in most patients.

Check out this study from the Journal of Athletic Training in 2015. They discuss how a patient’s flexion ROM can help significantly improve their IKDC scores (functional score) during the 1st 2 months post-op.

Simple Modification to Prone Quadriceps Stretching

I began to think about this topic when I was reading a Facebook post in one of the PT groups and it made me think. We always talk about knee extension and there is some research that discusses the importance of safely obtaining knee extension ROM. I put this study in a recent Instagram post and got some pretty good response.

It seems that whenever I talk about knee ROM after a surgery, people’s ears perk up. Let’s go to the video and talk about a simple technique I use to improve knee flexion ROM after a surgery or injury.

As you can see, a small tweak to your technique can really make a big difference. Again, I’m not sure what exactly is going on. It seems like I’m adjusting the position of the tibia just slightly and that is influencing the location of the stretch toward the quads. If I take my hand away, then they feel the pain and pressure in the front of the knee and it does not feel good.

Slow and Steady Knee Flexion

For the record, I’m not one of those PT’s that likes to be super aggressive and push my patients to tears. I’ve inherited those patients from other PT’s and that technique often fails.

When I talk about improving prone knee flexion, I’m talking about improving quadriceps flexibility and length. Remember, if you have someone lie on their stomach and you try to flex their knee, you’re either limited by pain, joint capsule or the rectus femoris (2-joint muscle.)

It’s not until I think the knee has reached a period of calm that I begin pushing into prone flexion. I’m not using this to crank and get 5 more degrees for my documentation. I’m using this at an appropriate time to improve muscle flexibility and maybe get that end range of motion that is so important.

Remember, obtaining full knee ROM is a process, but a very important process. it’s not going to happen quickly, especially if you’re wicked aggressive (my Boston comes out when I get fired up!!)

Try it for yourself

So this week, try this technique out on one of your clients who may be struggling with regaining their knee flexion ROM. I’m curious to know what you think and if it works for you. As we’ve seen, it’s very important to get that full ROM back after a surgery and this is one modification that I think can help you immediately.

 

 

If you want to learn more about how I treat ACL’s and other knee injuries, then you can check out our all online knee seminar. If interested, check it out at www.onlinekneeseminar.com and let me know what you think. We cover the anatomy, rehab prescription, ACL, knee replacements and patellofemoral issues both non-operative treatment and post-operative treatment. This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

Loss of extension after ACL surgery: How to assess for a cyclops lesion

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Loss of extension after an ACL reconstruction can be debilitating for the patient. It’s not as common as you would think but I see it enough in the clinic from people that are months out from surgery. Usually, this loss of knee extension after an ACL reconstruction is caused by a cyclops lesion. Let’s dive deeper into this!

Often times, they’ll present with anterior knee pain, posterior knee soreness and a relatively weakened quadriceps muscle that just won’t return. No matter what they do to get the motion back, the knee just never feels normal.

I’ve written about the loss of extension after an ACL reconstruction in the past. In this post, I discussed how I like to work on knee extension immediately after an ACL surgery. There are a few ways that I think are most effective and with minimal patient efforts.

What is a Cyclops Lesion?

For those not familiar, a cyclops lesion is a wad of scar tissue in the anterior aspect of the knee joint. It is believed to be a remnant of the previous ACL stump that had remained during the reconstruction surgery. At least that’s one theory. Another theory states that it may be fibrocartilage as a result of drilling the tibial tunnels.

Whatever the case, this arthrofibrosis (scar tissue) physically blocks the knee joint from locking out into full extension. Check out this MRI that shows the scar tissue in the anterior knee.

Cyclops lesion in the anterior knee blocking full (hyper) extension

How do I assess for a cyclops lesion after ACL surgery?

In this video, I describe why and how I assess for a cyclops lesion. Check it out.

Is it a Cyclops lesion or just a tight knee?

From the video, you can clearly note that anterior pain, in my experiences, is most often related to a cyclops lesion. Other factors to consider include:

  1. temporary/transient gains in extension
  2. anterior knee pain after increasing activity
  3. poor patella mobility
  4. quads just won’t come back
  5. continued hamstring/calf soreness

These are tell-tale signs that there’s more going on and you should refer back to the doctor so they can order an MRI to rule in/out the anterior scarring. If diagnosed, the best (and only) option is to have a knee scope and remove that scar tissue.

There’s nothing else that can be done. No PT, injections or manual therapy can restore full symmetrical knee extension.

The scar tissue needs to be removed by surgical excision. Aggressive PT should commence immediately after surgery to restore the extension range of motion.

The Best and Easiest Way to Restore Knee Extension after an ACL

Rehab after an ACL is never easy. There are many things that could affect a patient’s outcome. I’ve treated hundreds of patients after an ACL reconstruction and each one is a unique challenge. I wrote about this in a previous post here..check it out and let me know what you think.

I put this video together for Mike Reinold’s website so you could see what I exactly do to gain knee extension back….and why I’m not a fan of prone hangs. Hope it helps with some of your knee patients.

Final Cyclops Thoughts

As a PT or athletic trainer, don’t blame yourself if the patient needs another surgery to remove the scarring. It seems as if it was inevitable and was going to occur no matter the efforts to work on knee extension. I think the lesson here is:

  • work on extension early and often
  • maintain good compliance at home
  • assess/measure each visit to determine gains or losses
  • early patella mobility and knee PROM
  • get the pain and swelling out as quickly as possible
  • refer back to the doctor if the ROM not improving despite your best efforts

Hope this post helps you get better outcomes for your ACL patients!

 

If you want to learn more about how I treat ACL’s, then you can check out our all online knee seminar. If interested, check it out at www.onlinekneeseminar.com and let me know what you think. We cover the anatomy, rehab prescription, ACL, knee replacements and patellofemoral issues both non-operative treatment and post-operative treatment. This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

The Challenges of ACL Rehab- It’s Never Easy!

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It seems like I always have someone on my schedule that is post-op ACL reconstruction (or anything post-op, for that matter!). Although I thoroughly enjoy progressing ACL rehab because this population is very motivated to get back to their sport or activity.

Knowing that it scares the bejeezus out of me at times!

There are so many variables, almost too numerous to count, that can affect the outcomes. Some are modifiable and some are not. I wanted to take a moment and step back from the boring “just need to get knee hyperextension posts” that I’ve done in the past and take a more holistic approach.

The Little Details

For those that know me, this may be a bit of a stretch. But I honestly think that the little details of the process are just as important as the big picture. It’s like anything else, you need to focus on the little details in order for the final goal to be achieved.  The same is true for ACL rehab but I feel like this is something that is missed by many and can make or break a good outcome (which we know can be hard to find).

There’s a reason why nearly 25% of ACL reconstruction patients have a retear event and need a revision surgery. I’m not saying this is the only reason but I will say the mental aspect of the process can help the athlete during he process, and that begins post-op day 1 when they present to me in the clinic!

So, what’s going through my mind when I’m rehabbing someone after an ACL reconstruction?

via GIPHY

Human Soul, Mind, Spirit

From the get go, I’m trying to figure out the psyche of the person in front of me. Look up the word psyche in the dictionary and it means ‘human soul, mind or spirit’. This exactly sums up what I’m trying to define early on.

The tricky part is connecting with this person (and their family) so they can gain the utmost trust in you. You see, their future is in your hands so there’s a lot of blind trust that is going on early in the rehab process. They’re in pain, clueless to the process and hoping you know what the heck you’re doing.

I know the basic principles of ACL rehabilitation- calm the knee down, get their ROM back and get them walking/running/jumping. There’s a lot more to do but I’m being wicked brief, I know. And it does go way beyond that, trust me! It’s much easier said than done for most.

Some Factors to Consider

Each case involves a gazillion variable to consider when I’m trying to outline a logical rehab program. Often it can consist of:

  • pre-op status
  • graft choice
  • meniscal involvement
  • other joint issues (bone bruise)
  • revision surgery
  • surgeon
  • pain status
  • previous surgery (if so, how did that go?)
  • ultimate goal
  • school status
  • home situation
  • good support
  • insurance (not as much for me due to OON)

It goes on and on, trust me! If you don’t believe me, then read this paper that I found AFTER writing this blog post. Basically sums up my nearly 15 years of experiences very well. Check it out, if you want… Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review.

So my mind races as I’m trying to figure this stuff out. I’m also trying to sound half educated as I progress their program and observe their response to each new exercise, cue and bad joke I make.

Some people freak out with anyone touching their knee cap while others just sit there and chat it up. If I see the freaked out person begin to squirm, I need to anticipate that the next few steps may equally be a challenge for the client. Knowing that (and assuming that), I go into show mode and make every attempt to turn the focus from their knee and each and every painful bend or leg raise, to something very obscure. To me, it’s all about mind games.

Mind Games

Wait, I’m playing mind games with my clients? You better believe it. This is basically how I test my clients’ response to me, my personality, my rehab style and how the next 6-9 months will go. If I see a stoic, scared response, then I need to step up my game and find a common connection, QUICKLY!

The rehab especially at the beginning, is not about their flexion ROM or their swelling control but it’s about them gaining trust in me as their PT. Do they want to come to PT and put their complete future in my hands? Do they trust that I know what I’m doing and can lead them to their eventual goals? I hope so and it starts from that 1st joke I make or that 1st outcome study that I have to quote.

I don’t know which one will win them over but I have to be ready to offer either (or both). The last thing I need to happen is to have them show up for the next session and completely lose faith. If for some reason their swelling is up or their pain is worse (which happens in nearly 100% of the cases that I see) then I need to be able to talk them off the ledge and let them understand that it’s completely normal.

N=1 mindset

They have no comparisons to make. They also think their experience is worse than all others and that no one else has had swelling 2 weeks out of surgery. Or that all people can walk without crutches 7 days out of surgery, but they still have their crutches 14 days out. They have an n=1 mind and have no other experiences to compare it to but I have a database of cases to rummage through in my head.

Hope my mind can come up with a similar situation, make it real for them and get them back to reality…and get their faith back!

Trust me, no surgery is a guaranteed success and we know ACL surgery is a long ways a way from being perfect but we can truly make a difference by our confidence and personality.

I’ve made a career of this and can’t stress it enough!

Like the post? We have more to offer…

I hit upon all of this a little bit more in my online knee course that I have with Mike Reinold. If you’re interested in learning more about how we treat the knee, then go to our all online knee course that covers all topics including post-op ACL, TKA, PF surgeries. Also non-op treatment of the knee and a great overview of treatment progressions. The discussion boards are a great way to interact with other professionals and chat about the course and your own personal cases/experiences. Check it out soon!