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Extension deficits
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Extension deficits - December 11, 2005 4:16:00 AM
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Alex Brenner PT MPT OCS
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I sometines get patients after knee surgery that I can not get full extension with regardless of how aggressive I am. I typically use prone hangs, manual therapy, retro walking on treadmill and various bolstering techniques.
Does anyone have some good techniques or other ideas for getting those tough patients full extension.
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Alex Brenner, PT, MPT, OCS
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Re: Extension deficits - December 11, 2005 4:52:00 AM
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Diane
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How about neuromodulation? (Aka, "try a little tenderness.") Presumably healing is completed, stitches are long gone.
Patient supine, affected leg off the side of the bed resting on your lap. Catch the inner side of the lower leg up by the knee against the edge of the bed. Knee is slightly flexed. (Don't do anything to the joint, not yet..)
Palpate the back of the knee with your proximal hand. Find whatever back there seems to be gnarley or glued up. Moniter that continuously throughout (Moniter only, don't squish it or provoke it, just find it and sit with it): With your other hand, and telling the patient to tell you of any discomfort they may feel (gives patient control of the process), s-l-o-w-l-y press their foot toward the bed. Just a little, and for a long time, like maybe a minute and a half. Go slow, stop, go a bit more, stop, only go as far as you need to to start to note a change behind the knee. Shouldn't neeed more than an ounce or two of pressure because of all the great leverage. Wait until it feels like the back of the knee has softened completely and the tissue all feels homogenous. Then carefully ease off the pressure, extend the knee, lift the leg back up on the bed for the patient, keeping your hand on the back of their knee the whole time. Once it's up on the bed, have the patient tighten their quads a bit, a time or two. Take your hand off them completely at that point. let them bend their leg up and stretch it out a bit, then ask them to stand up and move around. They will report their leg feels better in some not very definable way, and they should demonstrate improved extension.
All you are doing is stretching their soft tissues around the knee with slightly sideways applied forces. The slowness of the technique allows for elasticity to reveal itself to the patient's brain. There seems to be no harm done, no pain caused. You are likely refreshing more than just their sensorymotor homunculus, you are likely stimulating increased blood flow to all inner aspects of the joint, and all the nerves that have to find their way through restricted tunnels around and back of the knee. It's probably that posterior tib nerve that benefits most, and its tunnel that will relinquish its death grip on the extension function of the joint. The slower you go the better. Give those tissues time to communicate with each other through the nervous system, and time for the nervous system to "make up its mind" that it prefers freedom of movement to lack of movement.
Good luck.
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Re: Extension deficits - December 11, 2005 5:41:00 AM
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jma
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There are times when I try prone hanging with a hot pack behind the knee to soften things up, instead of doing each separately. For those who are really motivated, retrowalking on the treadmill slowly inclining upwards seems to get things going as well. Not for everyone though.
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Re: Extension deficits - December 11, 2005 6:58:00 AM
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Jon Newman
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Hi Alex,
Are you able to determine if pain is a limiting factor versus a physical inability? I had the opportunity to watch a manipulation under anesthesia of a total knee replacement in which the person literally did not have the ROM (ROM under anesthesia was only 5 degrees more than we got in PT). Even after manipulation there was not much more to be had. She was actually a bilateral TKR and the other knee did fine so that was interesting to me.
What degree of extension are these folks getting stuck at that you are speaking about?
I ask that because I'm not sure at what point chasing down extra degrees is somehow important to the rest of their life in terms of quality/quantity keeping in mind the personal cost to get it. I don't actually have an answer to that question from the literature and I'm sure it varies by personal circumstances but I've met people who are quite satisfied with their surgery and outcome despite a 'minor' lack of extension (<10 degrees).
My experience is largely limited to TKRs however. I rarely see ACL repairs, etc but I think the same questions apply.
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Extension deficits - December 11, 2005 8:15:00 AM
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Geert Jeuring
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From: Möhnesee, Germany
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Hello Alex, in Germany we´re discussing arthrofibrosis for those cases. If your German is sufficient you can send me an email and I´ll send you the articles. Maybe the introduction is in englisch as well
Geert
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Re: Extension deficits - December 11, 2005 8:51:00 AM
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nari
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I tend to agree with what Diane and jon have written, and have little more to add.
Neuromodulation techniques can have a remarkable effect, but it seems like the intractable ones will just have to function without full extension.
Sometimes it will return with time; but forced techniques probably won't work and create a sense of 'failure' in the patient - perhaps.
Many people function quite well without 4-5 degrees; unless they want to go mountain hiking, and I guess there aren't too many of them...
Nari
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Re: Extension deficits - December 12, 2005 6:25:00 AM
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Shill
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Alex,
If you have the luxury of another pair of arms, having someone apply strong distraction while you apply the extension mobilization or prolonged stretch can be helpful, and less painful. I have also seen gains in a very small number of patients by working aggressively on prone flexion. Its weird, but they flip over and have improved extension.
Have you considered the JAS (Joint Active System)for knees? Its a prolonged stretch system, expensive, time consuming, but well designed. You could google them for the address
Steve
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Steve Hill PT
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Re: Extension deficits - December 12, 2005 7:06:00 AM
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JLS_PT_OCS
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Alex-
I have this problem sometimes, too, and I have been investigating why, clinically.
In this case I'm talking ACLR or knee arthroscopy folks who are lacking 10 deg or less, when the PROM is limited by what feels like a capsular type end feel. The consequences in terms of shear forces on tibiofemoral cartilage and the poor quad development that I believe is consequent to this is enough to make me concerned about trying to get every bit of extension that I can.
I have noted that some of these folks have any number of the following impairments, that when addressed, seem to move things along pretty well:
1. Excessive external rotation range of motion in their involved hip
2. Loss of IR in the involved hip
3. Decreased hip extension strength and/or ROM
4. Dec hip extension ROM during gait
5. Predilection for bearing weight on nonsurgical leg, with the involved held in ER and slight flexion
6. Inability to get good femoral IR toward full extension to complete the screw-home at the knee
I'm not sure why some people end up with this and others don't. It seems that the nicer I am to people about their ROM, the worse the extension is, and when I start them on prone hangs right away like an uncaring jerk, it's less of a problem. However, I am beginning to think that the answer has to do with soft tissue mobility at the posterior knee (and I like Diane and Steve's suggestions for resolving that) and/or hip function, as I allude to above.
Also, the latest knee OA RCT by Deyle et al has some specific ideas for knee manual therapy and exercise that might be pertinent.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Extension deficits - December 12, 2005 12:51:00 PM
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truthseeker
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I also see what Jason listed. Number 6 on his list is one that a lot of people forget about. A functional way to get the necessary transverse plane motion at the knee is this.
Have them stand perpendicular to a wall with their involved side closer to the wall. have them do a squat and reach low and away from the wall with both hands. Then, they come up out of the squat while rotating over the involved knee so that both hands are on the wall overhead. Do this while keeping both feet planted ( the uninvolved heel can come up a bit) Have them repeat it 20 times or so. I have used this technique with good success when the manual therapy hasn't worked.
I also have found that the bigger the jerk (read tough love) the therapist is during the first few weeks of rehab, the better the outcome.
Also, several articles say that the best predictor of post op motion is pre op motion so you may be fighting a losing battle.
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Re: Extension deficits - December 12, 2005 1:36:00 PM
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Jon Newman
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Unlike Jason and Tom, it has not been my experience that being a "jerk" early has improved outcomes. I ought to know because I'm somewhat of an expert at being a jerk.
What I have noticed is that those who are persistent and pursue the ROM they desire do the best, with or without me. Conversely, those who avoid motion the best, do the worst. How someone gets to have the kind of motivation needed is the therapy part and is worth reimbursing me for.
That said, I might be able to "save" someone unable to put themselves through what it feels like to tolerate the motion they already have. I write the previous sentence that way because most of these folks would demonstrate fine ROM if they were under anesthesia. We aren't actually stretching out anything but rather increasing a person's tolerance for ROM before they tighten up. I mean it's not like the surgeon crosses her fingers and hopes the knee works before getting them off the surgery table. The ROM is already there.
Jason, I'd be interested on any elaboration you have to offer on your statement
[QUOTE]The consequences in terms of shear forces on tibiofemoral cartilage and the poor quad development that I believe is consequent to this is enough to make me concerned about trying to get every bit of extension that I can. [/QUOTE]I agree we should encourage as much ROM as the patient can produce. I'm interested if you have specific literature (not necessarily journal articles) that influence your thoughts here. I've struggled with this dilemma and now that you bring it up I guess I still do. I'm uncertain about the real consequences of a small degree of flexion contracture.
jon
ps none of this means I don't ask someone to lay prone.
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Re: Extension deficits - December 12, 2005 2:18:00 PM
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srcase
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A couple of thoughts struck me while reading this: I agree with Jason in that a lack of full knee extension can have effects up and down the chain, the most obvious being lack of heel strike in gait, shortened stride and subsequent tightness of the contralateral hip flexor (or both). I'm sure there are more biomechanical considerations, but I always thought full knee extension was very important for gait.
I love Tom's idea of an active diagonal reach to improve hip control and rotation, thus affecting the screw-home mechanism of the knee. Retro walking is good too. Passively, I would also try Kaltenborn femoral dorsal mob (supine, stabilize tibia on wedge and mobilize femur dorsal) with a little femoral IR or ER and mob each femoral condyle separately. This usually works to get the last few degrees of extension and addresses the rotational component.
I sometimes do prone hangs early on for hamstring stretching, but worry about joint shearing forces too. Jon, in your patient who didn't get full extension even post MUA, I wonder if she had the wrong sized prosthetic components implanted?? Although, that usually limits flexion.
And lastly, the neurodynamic/soft touch approach can't be overlooked, as it often is. I might suggest gentle touch to the hamstrings and calf in prone to promote that neurogenic relaxation. Speaking of that, does anyone do contract-relax stretching for this?? Ok, enough rambling.
Sarah
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Re: Extension deficits - December 12, 2005 4:49:00 PM
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nari
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I have to agree more with jon's idea that we aren't dealing with stiffness here, per se, because extension is usually the first focus immediately post-surgery, followed by graduated flexion work. Sounds like a lack of awareness of the feeling of extension; do we know anything about the knee prior to surgery? It may have been flexed a bit for ages...
Which is why Diane's method is probably more useful than coercing hamstrings and other things passively. Standing and reaching diagonally certainly sounds good, but what does it say to the patient's brain unless they are watching it closely as they move? Being out of touch with the sensation of full extension is a sort of stiffness, but not caused by the joint.
I think I would do neuromod stuff, easing from the inner range to wherever the knee will go. Talking to the CNS is always worthwhile, no matter what the problem is. You never know..
Nari
Just a few cents' worth.
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Re: Extension deficits - December 12, 2005 10:23:00 PM
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Alex Brenner PT MPT OCS
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This is great advice everyone.
Jon, my more resilient patients are those with a greater than 10 degree extension deficit and seem to have more physical limitations than pain. There is almost always some discomfort when moved into these limitations but for the most part I feel that I am able to observe a physical restriction similiar to what Jason describes above.
Diane,
You provide some thoughtful interventions and I would like to learn some of these technique. I would think your techniques would be more effective on someone limited mostly by pain. Are you able to get good results on patients that appear to have more physical limitations such as scarring/fibrosis, or capsular restraints?
Tom, Steve, Sarah, Nari- Great ideas and things that I have not really thought about before. I appreciate that.
Jason, Great list. This would be a great topic to write a lit review for publication. You know, with all that extra time you have laying around :)
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Alex Brenner, PT, MPT, OCS
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Re: Extension deficits - December 13, 2005 1:20:00 AM
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Jon Newman
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Hi Alex,
If that's the case (mechanical limit) and if you haven't had the opportunity, observe a MUA. The surgeon may let you feel the resistance of the limb to extension under those conditions. I think MUA is the most humane as well as the quickest method of getting that ROM. I seem to remember reading that there is an optimal window of opportunity that is relatively early in the recovery process.
Hi Sarah, I suppose it could have been (suboptimal prosthesis) but I wouldn't bet on it based on the experience of the surgeon. I've done some lit review on stiff knees and ultimately they don't know what causes them at least at the time that I did the review.
Despite my interest in pain studies I remain impressed with the large variety of responses to essentially the same surgery. I'm especially fascinated by the differences in recovery of one knee compared to another in the case of bilateral TKA.
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Re: Extension deficits - December 13, 2005 2:46:00 AM
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Diane
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Alex,
[QUOTE]I would think your techniques would be more effective on someone limited mostly by pain. Are you able to get good results on patients that appear to have more physical limitations such as scarring/fibrosis, or capsular restraints? [/QUOTE]Yes, this approach works for pain, clearly.. I evolved it to deal with conscious/reluctant people in pain. It works for the other stuff too, in fact I sort of almost don't believe in scarring or fibrosis or capsular restraints anymore.. Rather, let me put it this way: the brain's ability to mimic these sorts of things as a protective output is uncanny. Let's just say, this approach can help the brain undo pretty much anything it has placed as a defense, and help it achieve more normal output, tissue feel, behavior. elastic recoil. If there truly is a mechanical limit, then this approach won't work and I agree with Jon that MUA is the right way to go. But how do you "know"? Therefore this approach is a good screen to find out if they need MUA (mostly they won't). Also, for an awake approach, it is more humane than anything else I've seen, tried, or done, in 35 years.
Diane
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Re: Extension deficits - December 13, 2005 2:56:00 AM
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JLS_PT_OCS
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Jon-
I haven't look at it in a while, but my concerns stem mostly from our knowledge of kinesiology and joint reaction forces. Given the recent theories about the etiology of early knee OA, that many of our young patients s/p arthroscopy are heading in that direction (alex and I should know) I think that concern about these "biomechanical factors" is warranted. I don't think I can make a case for the importance of full extension from the literature(and thanks for the 'out' by the way) but I think I can make a convincing case for everyone based on:
1. Kinesiology
2. Joint reaction forces
3. Clinical experience
And, in the absence of outcomes evidence, that's not too bad, I don't think.
Interestingly, after my knee arthroscopy in 1993 (as a young Army private) for a dislocated patella, I have had a similar extension lag, very small, but perceptible. This makes good quad development difficult, not to mention explosive strength is significantly reduced. I had thought it was a soft tissue restriction problem in the posterior knee as well as a hip movement problem. After several years of forcing things without too much luck, I think that Diane's gentler approach is more of what I need. Interestingly, the stronger I keep my knee through weightlifting, the less pain I have in the PF area and the easier the movement is overall. I am starting to think this has more to do with movement patterns in my walnut-sized brain than with any "scar tissue" that I need to break through, somehow. The Universe has seen fit to teach me many lessons on health and healing through personal experience, and I guess this is just another one of those...
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Extension deficits - December 13, 2005 6:18:00 AM
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ALICIAPT13
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Have you tried extension mobs, lateral rotation mobs, or distraction?
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Re: Extension deficits - December 13, 2005 7:54:00 AM
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JLS_PT_OCS
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Alicia-
Lateral rotation of tibia or femur?
I do mobs with a lot of patients, it seems to work only on those patients who weren't that bad off anyway. Those who are really stuck seem to not progress with these. I am beginning to wonder if my approach is perhaps too forceful, where something more gentle (a la Diane's suggestion) might work better.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Extension deficits - December 13, 2005 9:16:00 AM
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Jon Newman
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Has anyone noticed that people are able to achieve more extension ROM is certain postions than others and it doesn't always follow what you'd expect. For instance, it is not uncommon for me to find that someone can achieve greater extension in long sitting than supine.
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Re: Extension deficits - December 13, 2005 9:46:00 AM
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nari
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Supine lying is often a problem when assessing a structure - I think the brain does not like the position much. Not sure why, but many chronic pain people have difficulty and demonstrate all sorts of negative responses when supine lying, and pain usually increases.
With constraints such as capsular tightness, fibrosis and other things that Diane mentioned, it is amazing how, sometimes, the restrictions vanish with neurodynamics. Of course that doesn't happen with true adhesions; but it is an area where labelling can get us into trouble simply because there is 'tissue restriction'. The brain decides to put up all sorts of fences and guard dogs when it is cranky enough about the situation.
As in the case for 'adhesive capsulitis'in the shoulder, most cases will resolve spontaneously in 12-18 months....it pays to think about that for a while and ask 'why'..
Nari
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