I'm on my musculo out-patient's prac and have a patient who had undergone an ACL reconstruction 10 weeks ago. She is a young netball player with no other complications other than a stiff knee. Her strength is good in the available range. I can't test strength between 0-20 degrees KF because AROM=PROM. My problem is that no matter what I do there is very little improvement in her extension ROM or flexion ROM for that matter.
Following the op she had full knee extension but at about 4 weeks post op suddenly came into physio with a knee extension lag of about 20-25 degrees. She has made no improvement in the way of extension for the last 6 weeks and currently her range is 20-75 degrees knee flexion??? Initially we thought that the restriction of knee extension was due to tightness posteriorly and muscle guarding of hamstrings +++. Since then we have been doing lots of STM and release of H/S, popliteus and gastroc. We have also tried an array of other techniques: med/lat glides of the patella, lots or IRQ stuff (active and act/assist), hold relax techniques, massage, trying to facilitate extension by using gait. She is still managing the swelling with application of ice. She also has an intensive HEP which she appears to be adhering to???
So what are the possible reasons for her lack of progression, or more correctly her regression? 1) Not complying with HEP 2) increased intra-articular swelling 3) increased muscle guarding H/S. I can't think of any other reasons? I've pretty much tried everything I can think of as well as supervisor input and CCT input so if anyone has any sugesstions, please feel free?
It's a very frustrating case for both the pt and the PT. She keeps coming week after week with no improvement and all she wants is for it to get better so she can get back to doing the things she used to. She's not much older than us so it must be pretty demoralising, especially if you are doing your HEP and not getting anywhere. As the treating PT it's hard to know what to do. From talking to other PT's, with more experience, I've learnt that sometimes you can do all the right things during Rx sessions but if the pt doesn't take them on board and put the strategies into practice through gait or everyday activities then there's not much more you can do about it. I think it's one of the harder lessons to learn a PT - sometimes you can't do it all and you don't see much of an improvement.
2 comments:
Hey Mel, thanks for the post. It's frustrating when things are not going the way they should.
I'm at Charlies doing musculo outpt. One of the possibility is from the ACL recon itself, the new graft might just be tighter so maybe restricting her from full extension (i'm guessing) OR that she have hyperextension in her other knee so the bad knee is perceive to have an extension lag?
Have you tried any Mulligan's technique? To increase flexion, try get her to actively flex in standing and you apply an internal rotation glide on the tibia, as knee flexion is coupled with int rot. You can do that for ext, coupled with ext rot Mulligan's. Maybe ask your supervisor to show you.
Also, does she have a leg length discrepancy? Maybe worth looking at, lemme know if you still have problems.
Yeah i can see that being pretty frustrating, especially since you seem to have exhausted nearly all options. I had to follow up a pt post ACL recon and he was no longer attending physio as his graft was incorrectly placed and needed to be re-set. Do you think this could be a possibility? The physio before me addressed the issues you mentioned and did not have much luck, but on follow up with his surgeon they found the graft had been incorrectly placed. Just a thought. Thanks for a good post.
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