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Re: Extension deficits
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Re: Extension deficits - December 13, 2005 4:38:00 PM
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szckmc
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i do pretty well with knees, but in order to help you, more info is needed. There is a big difference between an acl recon. four or six weeks ago that has not obtained full extension yet, compared to a tkr on an elderely person with low pain tolerance. If you have a knee extension machine that can lock in place, you could extend their knee in sitting and have it locked into the machine, thereby giving a tolerable low load, long duration stretch, at no cost to patient or your hands. Other than that, extension mobes p/a with a lot of tibial ER force.
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Re: Extension deficits - December 14, 2005 2:59:00 AM
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dosrinc
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i am always cautious about utilizing the principle of Creep (low load, long duration stretch) unless I am absolutely sure that I am dealing with true adaptive shortening of tissue and not neuromodulated gaurding. Seems to me that true shortening takes longer (6 months or so) than most of us see our post op pts so the creep aproach doesnt make much sense to me and I avoid it secondary to the shearing forces mentioned above, If I did feel the tissues were truly shortend then I go with dynamic splinting vs something like prone hangs because to lengthen these tissues takes Low load and looooong duration, not something you tend to get with 10 mins of prone hang.
I have had good success combining the slow, easy release techniques in a fashion similar to what Diane describes combined with the posterior glide of the femur on the tibia as others have discussed.
Another functional way to get that last 10 degrees or so is to utilize MET or STEP principles: Pt stands facing one pulley with another pulley behind them, the anterior pulley is attached via cuff around the proximal tibia, the posterior pulley via cuff around distal femur, both with 5-6 kg pull. (you can use Tband if you must), the pt can then perform mini squats, TKE's and step ups with these pulleys acting to promote the arthrokinematics of extension (ant glide of tibia, posterior glide of femur) and also working on neuromodulation through stimulation of the mechanoreceptors in the joint capsule. I have had many pts reach full extension actively for the first time utilizing this set up which also provides for modified tension in the line of stress of the ACL.
Rick
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Re: Extension deficits - December 14, 2005 7:13:00 AM
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Alex Brenner PT MPT OCS
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Man, good stuff Rick.
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Re: Extension deficits - December 14, 2005 8:29:00 AM
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Synergy
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Very cool idea Rick! I'm definitely more of a visual person so I'll need to read it a few more times and 'act it out'.
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Re: Extension deficits - December 14, 2005 9:32:00 AM
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JLS_PT_OCS
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Rick-
Could have had a V8!
Awesome, why didn't I think of that?
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 14, 2005 1:26:00 PM
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KAK
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[QUOTE] For instance, it is not uncommon for me to find that someone can achieve greater extension in long sitting than supine. [/QUOTE]Jon I too have seen this with TKAs, and have pondered… why? I like Nari’s explanation. Maybe there is something about the vulnerability of the supine position that causes guarding.
Rick- Nice Idea!
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Re: Extension deficits - December 14, 2005 3:43:00 PM
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Diane
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Or, perhaps there is some tension in something in the anterior hip crease, or hip flexor, that doesn't let the leg relax down easily..
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Re: Extension deficits - December 14, 2005 5:47:00 PM
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Jon Newman
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While not exactly on target, I thought the following abstracts sounded interesting.
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16052589&query_hl=9]link 1[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16255022&query_hl=9]link 2[/URL]
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Re: Extension deficits - December 15, 2005 12:16:00 AM
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KAK
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[QUOTE] Or, perhaps there is some tension in something in the anterior hip crease, or hip flexor, that doesn't let the leg relax down easily.. [/QUOTE]Yes I've considered this, but when I put them in sidelying and check mobility of hip extension it is typically fine.(?)
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Re: Extension deficits - December 15, 2005 2:40:00 AM
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Diane
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[QUOTE]Yes I've considered this, but when I put them in sidelying and check mobility of hip extension it is typically fine.(?)[/QUOTE]It hasn't anything to do with the joint, so yes, actual active movement is ok.
But in static supine lying, upward pressures into the pelvis through the sacrum create greater passive hip extension than in sidelying active.
The restriction is not in the joint or joint capsule, it is in the soft tissue of the inguinal area, specifically one or more of the neural tunnels through which the cutaneous nerves fan out through or over the inguinal ligament. Treating these carefully (I treat them with the legs up over a bolster) can increase comfortable passive hip extension by quite a lot; then the knee can lie flatter too.
All that is required to treat and/or rule out this possibility as a complication, is to palpate the front of the hip with the legs up over a bolster, starting lateral with the lateral cutaneous n. of the thigh. (First tell your patient what you want to do, and why. Show them a picture from Netter's of the nerves in the area, so they know what you're doing there, and give consent.)
It will feel like a little banjo string in there, if it's tight. It usually doesn't hurt or bother the patient, it will just be tight. One has to make a bit of a mental leap here, to recognize that tension here is enough to persuade the brain to not allow anything like full hip extension in supine, and to decide to treat the neural tunnel. Treatment is to palpate it with one set of fingertips, place the other set an inch or so caudal, on the thigh, and slowly pull some skin caudally a bit, until you feel the "banjo string" soften under the palpating fingers. Then hold for as long as a minute or two minutes. When you're sure it won't tighten again, slowly let go. It should feel loose to palpation after. While the legs are still up over the bolster, you can palpate the more medial nerves as well. The most medial ones will require more flexion/abd of the hip: This can be accomplished by the patient propping their foot up on the bolster and letting the knee drop out against you.
Sometimes all of them are tight. Sometimes only the lateral cutaneous is tight.
It's worth doing, as you can gain substantial amounts of hip extension range with minimal effort/discomfort from you or the patient. And when the hip is able to drop back in supine lying, you'll be able to see if the knee is for sure restricted in extension or if it was just dangling because of the hip tension.
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Re: Extension deficits - December 15, 2005 2:42:00 PM
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Jon Newman
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A couple more links to pubmed abstract although they are dated.
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9046510&query_hl=13]posterior capsulotomy[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12897981&query_hl=17]post-op bracing[/URL]
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Re: Extension deficits - December 15, 2005 3:04:00 PM
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srcase
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Interesting analysis Diane. I also wonder how much the iliopsoas has to do with this discomfort in supine. It's attachment to the lumbar spine, and lengethened position in hip extension may account for a protective response if the body is trying to protect against neural irritation. Your technique sounds similar to the Jones strain-counterstrain position for iliopsoas. Just a thought.
Sarah
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Re: Extension deficits - December 16, 2005 1:15:00 AM
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KAK
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Thanks Diane.
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Re: Extension deficits - December 16, 2005 11:47:00 AM
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Alex Brenner PT MPT OCS
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As always, great links Jon. I am not able to get full copies of the text at this time but will try so when I am back home.
I am interesed in reading about the capsulotomy. It is an older article and describes a surgery that I have never seen conducted. I wonder what the current thoughts of are for this in orthopaedic surgery.
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Alex Brenner, PT, MPT, OCS
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Re: Extension deficits - December 16, 2005 6:21:00 PM
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Jon Newman
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Here's an article on the the knee and corrected morbid obesity.
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16354524&query_hl=1]link[/URL]
Alex, I'll ask our ortho docs about their view on extension deficits as well as capsulotomy. I've never seen one either.
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Re: Extension deficits - December 17, 2005 7:04:00 PM
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james097
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From: West Vancouver BC
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Jon, The National Health Service in the UK gives monies to regional districts to pay for srvices.
Many of these boards are deep in debt and have to cut back on spending. The first initiative of some boards is that they will not pay for hip or knee operations if the patient has a BMI of 30 or over. I suppose they consider it a self inflicted wound. I wonder if smokers drinkers, and those with athletic injuries will be next.
James
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Re: Extension deficits - December 18, 2005 2:54:00 AM
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Jon Newman
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Wow, that's too bad James, on all levels. I'd be interested in their official justification for that as I'm sure there must be one. If it is as you stated, I think a legal battle would likely ensue if it were the US.
Interestingly, a trend I've noticed is that obese people tend to have great early knee ROM status post TKA. Has anyone else noticed that or am I suffering from a sample bias?
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Re: Extension deficits - December 18, 2005 3:33:00 AM
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jma
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That is very surprising James. I have never heard of that kind of inititative before.
As far as ROM post TKA in patients who are obese, I have not seen that kind of trend down here.
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Re: Extension deficits - December 18, 2005 5:21:00 AM
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SJBird55
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Jon, I don't see that trend either. Without looking at data, and if my reflections are correct, obese women tend to have a more difficult time after a TKA in regard to both pain and mobility. For some reason, I've always wondered about the fit of the components versus blaming it all on obesity.
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Re: Extension deficits - December 18, 2005 8:17:00 AM
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james097
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From: West Vancouver BC
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Type in on your screen, guardian unlimited knee or obesity uk knee operations. A portent of things to come?
James
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