regarding postop physio

[Melissa1]

Yes, very similar...but my PT said it puts less pressure on the affected knee.

[Jaci]

Hello ermin,

I think it's smart to keep working on the extension. Frankly, I think your PT is jumping the gun a bit with lunges and standing wall slides. Generally those sort of things would not be added until you have full ROM. The standard accelerated rehab protocol (the one that Noyes, Steadman, Shelbourne, and other pioneers developed) focuses on early ROM, there are goals and phases to the rehab, and reaching the goals of one phase is what indicates that the patient is ready to move onto the next phase. I think many PT's get hung up on up on the 'time' aspect. In other words, the patient is X weeks post-op so should be doing these things, so the protocol rather than the patients progress is driving the rehab, when it should be the other way around-- The patient's progress drives the rehab, and tells what should be focused on. If the the patient does not have full ROM and good joint mobility, that should be the focus.

I'm a patient of Dr. Steadman (in addition to knowing a lot about ACL recon and preforming them on some of the best athletes in the world, he's also one of the few experts on arthrofibrosis, which is why I see him.). He always says "if a patient at 6 weeks after surgery has good strength but decreased mobility, it's almost 100% they're going to need another surgery for mobility. If they have good mobility, they can always build strength, and it's almost 100% they'll be successful."

Getting on an exercise bike should help. Also, it's probably best to not use ice and weights at the same time. You want to apply the weights to your leg when the muscles are warmed up and pliable, your leg will stretch better that way, which facilitates gains in extension. Elevating and icing is completely separate, prop your leg and knee up and let it relax while your icing.

Take care,

Jaci

[ermintham]

hi jaci,
        ok then i think i will put more emphasise on rom for my home rehab. i get this sharp pain at the back of my knee whenever i try to bend /straighten after straightening/bending for a long time. my PT attributes it to a tight hamstring and advices me to do more hamstring stretches. any thoughts? one more thing, for the flexion, can i jus sorta force it to bend more? coz i feel pain at the end of the calf near the back of the knee cap and pain at the end of the hamstring when i try to flex it.

ermin

[Jaci]

Hi ermin,

Sounds like a good idea.

One thing that I found helpful was to break my PT up into a few mini-sessions each day. I would work on extension during one session and flexion during another. There were certain things-- like patellar mobilizations, quad sets, SLR, and stretches that I would do every session. Then I would do either heal props with a light weight above my knee for extension. Or, lying wallslides and low load prolonged stretching (LLPS) for flexion. These are described in Part 1 of the rehab for arthrofibrosis tutorial.

It's okay to force a little bit when you are doing lying wallslides or LLPS for flexion, but you should do it passively rather than engaging the hamstrings to try to pull more. For example, when you do lying wallslides use your good leg to support your affected leg as your foot slides down the wall. Let gravity do the work. As you go down the wall your good is under the affected one for support, when you get down as far as you can go, then postion your unaffected on top of your affected leg and lightly push down to get a little more bend. Hold for a count of ten, then reposition your good leg so that you use it to push your affected leg back up the wall. This exercise should be done slowly and in a controlled manner to gently increase flexion. There is nothing to be gained by pushing too hard or being too aggressive, you do not want to irritate your knee and cause an increase in pain or swelling.

When you do the LLPS for flexion use gentle pressure to pull back on your leg. I found that it worked best to initailly put my hands under my thigh and pull back toward my body, as your thigh comes up and back your foot slides back as well, causing your knee to bend. Once your knee is bent enough for you to be able to reach down in front of your shin, then gently pull back and hold. The instructions in the tutorial say to hold for 10-30 minutes. When I first started, I could only hold for a few minutes before having to straighten my leg. When you need to straighten use either your hands or your other leg to assist with straightening. Let your leg relax for a few minutes, then repeat. I would sometimes have to massage my knee and leg to get things to loosened up before bending again. Like I said above, the key is gentle stretching. You should not have a huge increase in pain during or after the exercises.

Take care,

Jaci

[ermintham]

thanks jaci. so regarding the pain when straightening after bending and vice versa (this pain only lasts a few seconds...). is it due to tighten hamstring accordin tomy PT?

[ermintham]

hey, i went to the gym today to do the bike. had a hard time getting quads to work. coz i dun cycle normally. i can feel m injured leg is using my calves to turn it. so tryin to cycle properly, i was able to feel my quads work a lil.

most of the probs were due to my scoliosis, which made me sit slanted to one side...for that matter, my uninjured side, thus it works my uninjured side more. haha life sux

jaci, i wud like to know if the lack of muscles will lead to me not being able to maintain my extension( according to my PT)? or is it due to the tight graft ? if so, how do i stretch the graft. i cant maintain my extension. every morning i wake up, i cant extend. i have read in this forum that there are pple who have almost no quad muscles but are able to have full rom.

[hntndaylight]

Sounds like at this point you are way ahead of me. This might help someone following this thread (I just found it, sorry). I was in an immobilizer for 2 weeks post accident and no PT for 2 weeks post op (banaged in a 6" thick wrap for 2 weeks). My quads were gone when I started PT (e-stim first) I pushed, strained, cryed, and still couldnt use them. Brain just didnt connect any more. When they did try to work, my hamstrings pulled in too and pulled in stronger (they used a quad tendon as the graft for mine)

Finally, on one of my at home workouts, I asked my mom to lift my leg verticle, perpendicular to the bed and see if I could hold it. It worked. From then on the PT and OS have had to make me slow it down. I want to force an aggressive PT to break up scar tissue but evidentally they are in lock step that there is too much mess in there to risk aggressive. I guess they are right, when I do push I blow up in swelling. I've come to accept it when they say severe restriction for 12 weeks, moderate restriction for 36 weeks, and then brace only for another year. 

[Jaci]

Hi Ermin,

Glad you were able to get on the bike. It's okay if your 'good' leg is doing most of the work right now. Use the bike with no resistance and just peddle. It's good for loosening things up. Is it a regular upright bike or a recumbent bike? You may want to check the seat height. On an upright bike, I generally position the seat so it is even with my hip joint when I stand next to it. Try different adjustments until you find one that works well for you. I usually found that it worked best if it allowed my knee to be a little bent at the bottom of the rotation.

I thought of another extension exercise for you. It's called prone hangs. I have a love-hate relationship with them. Hate them because they hurt, but love them because they really did help with my extension. There's a picture of them in the protocl from Dr. Millett (the link I posted near the beginning of the thread). It's figure 2. in the photos. You lie on your stomach on with your legs hanging off the bed or PT table. Your knees are off the edge. I used a rolled up towel at my thigh for a little cushioning. Initially you may only be able to 5-10 minutes, but you want to work up to 20 minutes. If you need a break while your doing them, use your other leg to help you bend up the lower part of your affected leg and take the pressure off your knee for a few minutes, then continue. You can add a small weight-- no more than 1-2 lbs.-- once you work up to 20 minutes. When you first start using the weight put it on you calf, rather than down at your ankle.

Being able to maintain extension is not dependent on muscle strength. Remember ROM before strenthening. Yes, you need to be able to do quad sets and SLR-- those are really more for quad contraction, but your should hold off on weight-bearing strengthening until you have full ROM. Are you using e-stim in PT? Is there a way you can get an e-stim unit for home use? 

Here's a  link to transcript of a talk that Dr. Steadman gave on ACL recon:

http://video.medscape.com/pi/editorial/cmecircle/2004/3069/flash/steadman/transcript.html

Also, there are a couple videos on Orthosupersite that might be helpful for you-- "Postoperative ACL rehabilitation" "Rehabilitation and results" both talks by Dr. Steadman.

Here's a link to Orthosupersite. http://www.orthosupersite.com/

You'll need to register to access the video library, it's free. Then look on the home page. Lokk for "video library" toward the bottom of the second column of text. Click on it to go to the index for the video library. You may have to look through the few pages of titles to find what you're looking for because new titles are added to the front. Dr. S talks about some of the things that you are dealing with, so it would probably be beneficial to you.

Hope that helps.

Jaci

[ermintham]

hmm...i was doing both the upright and recumbent bike. hehe...coz i had to wait for my turn on the recumbent bike. i think i wud have to use the recumbent bike. the upright bike seems to be a lil too tall for me even tho the seat is quite low. im pretty short actually. 5'4''. i tried prone hangs b4. din really work. but will give it another shot. OK rom b4 strength. will keep that in mind. regarding the e stim. im off it alr. and nope i do not have it for home use.

i think my scolisis is killing me. it has led to my left , uninjured side to be stronger b4 my accident. now, with the atrophy, its even worse. for the normal slr, i can feel i am using my gd side to lift. and for the hip abductors.(did i spell correctly?) i also use my stronger side to life my leg up. haha. im screwed.

anyway, after those extension or flexion exercises. wat should i do? i usually jus use my comp or watch tv...and after a while. i lose that full extension.haha

one last thing, wat methods does ur physio use to measure flexion?

[hntndaylight]

one last thing, wat methods does ur physio use to measure flexion?

My PT measures hip bone to center of knee to heel bone in a straight plane for flex and extension. My OS measures bottom of thigh where is sits on table to center of tibia. OS always shows more flex than PT 

[ermintham]

haha yea....

i realised when sitting down...i get more flexion as opposed to heel slides which is on a straight plane.

gosh i cant keep my extension there all the time.

[ermintham]

hey jaci, i jus thought of something to ask.. i din have full flexion and zero extension when sitting (but nt walking) b4 my op. does that mean i will take a longer time to get back full range of motion after op?

[caroljm36]

Are you getting any assists when you start?   My quads quit on me after a LR and osteotomy.  But I had my husband lift my leg the first couple, just a slight lift with one finger--then let I the leg down slowly myself.   That part seems to wake up the quad.  Then after a few with decreasing lift on his part, I could do them myself for the rest of the sets.   

Rig a little rope pulley type thing over a doorknob or rail, just anything to get the assist if no one's around.   Later I could do it just looping theraband around my foot and pulling. 

It took a couple weeks but I was able to start the SLRs myself and now I'm doing great 4 weeks post op.

[ermintham]

hi carol. yea im able to slr already.. and i realised that the act of lifting and coming down is the one that works the quads and not the part whereby i maintain it in mid air. i have scoliosis. so i tend to use my noninjured side even b4 my accident. so its alr slowing me down a lot coz i tend to contract the muscles of my non injured side for the lifting.

[ermintham]

to anyone following this thread. i find that cod liver oil helps my swelling. i have been taking scotts emulsion cod liver oil. it works.

apart from that, i also massage it like jaci told me to. and i do a lil tapping on the kneecapwith my fingertips. i can feel tt something is going on. so for those who have stubborn swelling despite the regular RICE. u can try these suggestions