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Author Topic: Can you really get past flexion plateaus in ROM  (Read 6801 times)

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Offline overmodulated

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Can you really get past flexion plateaus in ROM
« on: June 12, 2003, 06:00:41 PM »
Hi folks:

I'd like to know the consensus: when one seems stuck and can't achieve further flexion in the knee, despite how much work they put into it, does this imply they're stuck for good?

Can this change over a significant period of time or does it require invasive procedures to correct?

I ask because I'm stuck just shy of 90 deg flexion following a tibial plateau fx repair several months ago.

Thanks much
« Last Edit: June 16, 2003, 05:52:11 AM by overmodulated »

Offline ATsoccergirl

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Re: Can you really get past flexion plateaus in RO
« Reply #1 on: June 12, 2003, 07:35:21 PM »
If you are working with a very good physical therapist, joint mobilizations can be used to increase ROM.   The therapist will apply a glide in the direction needed to increase either flexion or extension.  I'm thinking anterior glides are used for extension and posterior glides are used for flexion, but don't quote me.  Joint mobs can be quite effective.  The athletic trainer I worked with after my surgery used this technique when my ROM plateued at 110 afer having my knee scoped to remove scar tissue.  I quickly regained ROM to my current ROM of 125.  I have used a contract relax method with athletes to improve ROM.  The knee is taken to the end range of flexion actively.  The the quad is isometrically contracted and then I passively push their knee into more flexion.  My orthopedic surgeon is a big proponent of this technique.  
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.

Offline overmodulated

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Re: Can you really get past flexion plateaus in RO
« Reply #2 on: June 12, 2003, 10:16:19 PM »
Soccergirl, I too like that contract/relax method and it has gotten me where I am in flexion and even helped a little with extension.  After achieving some decent progress this way about 2 weeks ago, I haven't been able to go further.

I'm not familiar with the glide or joint mobilization tricks you mentioned.  Is this anything like a sliding/rowing machine?

Any more info is greatly appreciated.




Offline ATsoccergirl

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Re: Can you really get past flexion plateaus in RO
« Reply #3 on: June 13, 2003, 04:26:18 AM »
joint mobilizations are manuel therapy techniques used by certified athletic trainers and physical therapist
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.

Offline overmodulated

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Re: Can you really get past flexion plateaus in RO
« Reply #4 on: June 16, 2003, 05:56:30 AM »
bump...

I would still very much like to hear from anyone who has seemingly hit an early range of motion limit, and whether they were able to overcome it.  Based on the responses so far it doesn't look good.

thanks again.

Offline enuff81020

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Re: Can you really get past flexion plateaus in RO
« Reply #5 on: June 16, 2003, 07:21:45 AM »
my experience with rom and flesion is that i have increases then plateayus and then increases--it kind of looks like my weight loss efforts.   the good thing with both is that i  never  go  backwards...

when i had my tkr--i went from 60 to 80+ to 90 where i stayed for a while and then up to  112 and i plateued again for  a couple of weeks and then it fgradually got to  120.

i'm willing to bet you are doing better than that,  but it is wonderful  to have greater rom  after  a tkr than i had beforehand.  

i hope that you break your plateau soon--good luck, sylvia
Both kneesOA.
Scope on rt knee,9/00;2/01
scope w/ LR and debridement rt knee 2/02
left knee same5/02
Patellar problems
LeftTKR12/16/02
Right TKR7/14/03
Complications MUA 8/14/03
R TKR revisio

Offline jeanie

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Re: Can you really get past flexion plateaus in RO
« Reply #6 on: June 16, 2003, 02:09:00 PM »
hello overmodulated,
hope you get through your RoM plateau....it can be very frustrating. I've had a stiff knee for over a year following a skiing accident .....  been stuck at 50 flexion 20 extension for nearly three months .....that's after two MUA's attempted to improve the situation. I'm still going to physio , doing exercises  and swimming in an determined effort to get better. On my last visit to OS  I was told to expect my knee would always be stiff.....I'm not happy with this verdict and going for another opinion in a couple of weeks. There seem to be a few people on this board that have  managed to make good progress with perseverance and sometimes with some surgical intervention ........ I hope you get a breakthrough soon  ...... best of luck and let us know how you get on
Jeanie
Ski-ing 04/ 02. patella dislocation ruptured ACL MCL,  meniscus.10/02 MRI 11/02; ,menisectomy 2/03 MUA cortisone; haematoma/3/03MUA ;8/03 menisectomy,lysis adhesions 4/04 RSD/CRPS  2/05 Cortisone injection 11/05 lysis adhesions - infection 4/06 Botox injex hamstrings

Offline Janet

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Re: Can you really get past flexion plateaus in RO
« Reply #7 on: June 16, 2003, 10:59:13 PM »
At one point, I was not able to continue gaining ROM and was stuck at 70 degrees. I eventually had a manipulation under anesthesia and arthroscopy to get rid of the scar tissue that was binding my knee. Within three months I was at 120. Even though I would never recommend jumping into surgery, you can know there are surgical options is everything else fails.

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline overmodulated

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Re: Can you really get past flexion plateaus in RO
« Reply #8 on: June 16, 2003, 11:09:41 PM »
Thanks folks.

Enuff: how long were you stuck at 90?  (It's where I am stuck now).  And how long did it eventually take to get up to 120 altogether?

Jeanie: please keep us posted on your progress.  I am stuck somewhere between where you happen to be and where Enuff hit his first limit.  Good luck pushing yourself through this.  I know it's hard.

Janet: it is good to know there's an option to being forever limited in flexibility.  I couldn't complete a single cycling stroke right now, if I were allowed to (3 months post op).
Was the procedure or the recovery from it very painful?

Thanks again
« Last Edit: June 16, 2003, 11:55:35 PM by overmodulated »

Offline enuff81020

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Re: Can you really get past flexion plateaus in RO
« Reply #9 on: June 17, 2003, 02:10:20 AM »
hi again,

90 was a big deal to get to for my tkr--and then i was there for like 3 weeks--evn with a lot of effort.  the truth  of the matter is that it is important to stick  with it.  i could have stayed at sixty something--wouldn't have been unheard of given my condition...

i bet you will  get there--give yourself the time to strengthen and the encouragement you need to gve yourself.  let us know when the plateau breaks!  sylvia
Both kneesOA.
Scope on rt knee,9/00;2/01
scope w/ LR and debridement rt knee 2/02
left knee same5/02
Patellar problems
LeftTKR12/16/02
Right TKR7/14/03
Complications MUA 8/14/03
R TKR revisio

Offline Janet

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Re: Can you really get past flexion plateaus in RO
« Reply #10 on: June 17, 2003, 05:34:45 PM »
Again, I am not advocating further surgery. You really aren't very far out from surgery now. I know it seems like it, but in the world of knee surgery, you're not!

The recovery from the MUA was fairly uneventful. I was already in so much pain and so frustrated with everything, it was a relief to be doing something. I had never stopped PT since my original surgery, and kept right on with only a few days respite to recover from the arthroscopy. PT was painful....but gaining ROM is always painful.

I hope you don't need to go this route. It sounds like many others have been able to get the breakthrough they needed without surgery. I'll keep my fingers crossed that it works that way for you.

Janet
Torn quad tendon repair & VMO advancement 4/99, MUA with LOA 10/99, Patella baja and arthrofibrosis, LR & medial release & LOA 5/01, LOA & chondroplasty 6/03,TKR on 11/06, MUA 12/06. From perfect knees to a TKR in 7 years, all from a fall on a wet floor...and early undiagnosed scar tissue.

Offline lizl

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Re: Can you really get past flexion plateaus in RO
« Reply #11 on: June 18, 2003, 03:41:59 AM »
Hi, Overmod!

I have hit several plateaus with ROM. Each time, I bring my fears here to the board, and my KneeGeek friends chime in with the reinforcement and hints I need. Just today, for instance, I finally made full rotations on the stationary bike--after two weeks of near-depression over lack of progress in ROM! Just a degree or two at a time, but I'm so much encouraged.

I really hope you can see progress soon.

By the way, I have found it helpful to have the same therapist do the measurements each time. They are all supposed to measure the same way, but I don't think they do. One day I got really discouraged when it seemed that my ROM had gone backwards five degrees during what I thought was a pretty successful workout--and then the very next day, my measurement showed I was back at the point I had been earlier in the week. Honestly, I believe that the only difference was the interpretation of the two people doing the measuring! Now I try not to react to the results too much. I say "try" because I look to those numbers for encouragement--and when it doesn't come, it's tough to fight the discouragement!

There are other numbers besides ROM that can measure progress.  During my most recent ROM plateau, I increased the number of reps and the resistance (weight) on the machines at PT. Also, when it seems that you are just biding time, maybe you can take some comfort in doing things differently--like reversing the sequence of the exercises. At least, it will change the routine.

LizL
2003: 1/28-29Fell on wet floor,broke kneecap
ORIF(hdwr&immob)
Post-op drug reaction
3/4-5/13 brace
3/21-8/28PT
12/19Hardware removal,scope,partial meniscectomies
2004: More PT
lost job
Settledw/WC Oct
2005: Personal injury lawsuit--reschedulings,failed mediation
2006: settled out of court in March

Offline Heather M.

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Re: Can you really get past flexion plateaus in RO
« Reply #12 on: June 18, 2003, 03:59:30 AM »
Try not to get too frustrated.  Gaining ROM is one of the very hardest and most painful aspects of knee recovery, in my humble opinion.  And you've got a double whammy--tibial plateau fractures and patella fractures are notorious for lost mobility, and no one wants to push too hard for ROM because they are worried about the healing bone.  What does your OS/PT have you doing for ROM?  Here are some things I've done when I was unable to bend my knee after surgery and infection.  NOTE: don't try any of this without your PT or OS giving the OK!

1.  I've found the very best thing to be wall slides (lying on your back w/feet on the wall, good leg under bad supporting it and helping it bend).  I used to do these 4-6 times a day to regain ROM.  

2.  Also, sitting on a high counter or barstool and letting the legs simply dangle is quite helpful, or sitting on a chair with wheels and GENTLY rolling forward while keeping feet on the floor.  

3.  You can also lie on your back and have a trusted friend/companion support your leg while GENTLY going through some bending.    

4.  Another thing that works is sitting on a stationary bike and rocking GENTLY (are you getting the idea   ;)) forward and backward.  One day, you will just go all the way around without realizing it--what a victory!  Keep in mind that for some reason it's easier to pedal backward, so that will probably be best for you.  

For all flexion exercises, the key is to go as far as you can, hold at the point of discomfort but not true pain for 10 secs, and then release and try again.  If these don't work, and if you get the OK from your PT/OS, here are some other tricks I had success with: A.Sitting in a hot tub/shower and limbering the muscles up.  Then immediately begin your ROM work (you can do it in the hot tub if it's big enough).  Also, a heating pad wrapped around the knee/lower thigh can help warm up the muscles and increase flexion.  Be sure to ice as soon as you're done, because the heat often causes swelling.  B.The second key is pain control.  I was told to take a larger dose of painkillers about an hour before I wanted to do PT and ROM work.  That way, they are in your system and the pain won't keep you from making advances.   C. If you can, have someone massage the base of the quad and/or below the knee while you are bending.  If they can help relax the tight areas, sometimes you can achieve more flexion or even break some of the adhesions.  You might see stars if this happens, but it will lead to immediate advances in ROM.

Talk to your care providers about doing some of these exercises--they can really help.  I know how frustrated you are, I was stuck at 56 degrees of flexion for a month after having 2 scopes in a 3 week period of time.  After a full month of this torture, my doctor decided it was "too cruel" to continue, and he did a manipulation under anesthesia (no surgery, just knocked me out and bent the snot out of my leg).  I don't believe you are a candidate for this because of the fracture, but in your type of case there are other surgical options to remove scar tissue.  I don't think anyone would try it yet, though, because you are pretty early in the recovery.

Good luck.

Heather

« Last Edit: June 18, 2003, 04:06:08 AM by hmaxwell »
Scope #1: LR, part. menisectomy w/cyst, chondroplasty
#2-#5: Lysis of adhesions/scar tissue, AIR, patellar tendon debridement, infections, MUA, insufflation
#6: IT band release / Z-Plasty, synovectomy, LOA/AIR, chondroplasty
2006 Arthrofibrosis, patella baja
http://www.flickr.com/photos/hmaxwell

Offline overmodulated

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Re: Can you really get past flexion plateaus in RO
« Reply #13 on: June 18, 2003, 06:35:15 AM »
Very good feedback - I appreciate it all.

lizl: I too notice the inconsistency in measurement technique using the protractor.  My PT is the first to admit it is only a gross measurement, not an exact science - I could see the disparity in angle readings with the slightest adjustment in alignment.  But I am using the same therapist each time and I try to watch carefully while he takes the measurements.

Heather: very good advise.  I do your version of the wall slide while laying on the bed, called a knee slide.  Does it help much to be up against a wall?  I also sit and dangle the leg as you describe, and push on it in various ways.

You said two other things that are very interesting to me: (1) not wanting to push hard on the unhealed bone, and (2) infection.

I am on a strict non-weight bearing rule, yet I find my therapist pushing the leg in a direction which puts force against the tibial plateau, rather than just in a direction that rotates the joint.  I'm always reminding him about the direction of force and am worried about possible damage done to the healing bone.  Have you or anyone else been concerned about the workout technique in this regard?  My therapist hasn't worked on others with my exact type of fracture.  I wonder if it's safe to continue using him.

Infection: I have had a couple, and have been fighting them off with antibiotics.  Have you had this problem?  Was it a superficial stitch absess or something deeper, like rejection of the hardware?  Would love to compare notes with you on that issue.  I'm worried about what happens when I stop taking the antibiotics.

Thanks again people.




Offline enuff81020

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Re: Can you really get past flexion plateaus in RO
« Reply #14 on: June 18, 2003, 07:41:47 AM »
hi again,

i would like to reitterate what heather said about taking pain meds in a timely way before therapy.  that does put you in a potition to push it  bit farther--strengthen and get better.

after one of my surgeries--my left lr--my therapiststarted all of our sessions with heat on tht knee.  that sure acted to limber me up some so i could get at some of that very important bending and straightening.

i hope those thoughts help  you some.  good luck, sylvia
Both kneesOA.
Scope on rt knee,9/00;2/01
scope w/ LR and debridement rt knee 2/02
left knee same5/02
Patellar problems
LeftTKR12/16/02
Right TKR7/14/03
Complications MUA 8/14/03
R TKR revisio