Have you ever asked your ACL patients to hold terminal knee extension on a towel roll? Lie prone with the knee hanging off the table for 2 hours a day?  Many physical therapists and sports medicine specialists have. But there’s a better way. At the end of the day, we’re on the ground with clients, working with people on a regular basis, and we have some insights we’d like to share. Firstly, we share a common important goal when working with our ACL patients: to gain extension in the knee right out of the gate and as soon as possible. But we think that how you gain that extension is somewhat debatable, and we have seen a lot of stuff out there. We’ve seen holding the position on a towel roll, kneading the ankle for 10 minutes at a time, lying prone with the knee hanging off the table for a prolonged period of time. Odds are that you may have actually prescribed these or used these on a regular basis to really deliver the care. We approach it differently based on our insights and understanding of how the body works. First, we have to have an understanding of the neurology of the system and how the body works. When you’re working with a patient and you see that they’re guarded and stiff, your first instinct will be to gain mobility. When you go to gain that mobility and you push their knee into extension, how much are they really relaxing into that new range of motion? The nervous system is key here. Here’s an example. We work with a UFC athlete who had an ACL surgery, and oddly enough, right when we saw her two weeks out, she had perfect extension in her knee. She could activate the quad and it was pretty close to straight. Well, about a week later, she happened to overstress her knee because she tried to overwork her knee (not uncommon of a professional athlete), and once it got overworked and inflamed, she lost extension in a hurry. All of a sudden, it was the classic problem: “I’m missing 10 degrees of extension.” So now, I take this overstressed knee, and what do I do as a great clinician? I definitely don’t start pushing down on it to force it into extension. In reality, it was all about stress, because she had full extension two weeks out. Three weeks out, she didn’t. How about that? Another example is if you think about taking the nervous system out of the equation. In the operating room during an ACL repair, the orthopedic surgeon got full extension when the patient was under anesthesia. But now when they come to physical therapy after their surgery, they are nowhere close to full extension! What’s the difference? The nervous system. Okay, now you understand that the nervous system plays a key part in this. But if you’re not supposed to push the knee into extension, what should you do? Our job as physical therapists is simply to help the patient learn how to turn the quad back on. You’re just waking up the musculature that allows the knee to extend, while allowing the nervous system to relax into the new range. Let us explain. Think about this. The last time an ACL patient straightened their knee, they tore it. Whether it was a hyperextension injury, or maybe they twisted on it and it flared it up, this caused the injury in the beginning, and they haven’t really walked on it a ton since. Maybe it’s been three months or even six months since they’ve walked with full knee extension. The longer this period is, the longer it takes to get the full range of motion. So, what should you start with? I’d say that the research and the evidence strongly supports some deep pressure, prolonged holds, a little slower approach to get this gain in mobility. We also use the floss band, which is a phenomenal tool to put some compression on the knee. You may assume that compression is gonna tighten the joint and the tissue, but in reality, that compression provides neurological stability. And from there, it seems like you just see the knee go right into extension. How does that even work? It’s a different stimulus. The patient sees their knee getting wrapped and protected. They feel their knee getting compressed in a different way, and it’s just another stimulus for them to perceive from their environment to say that it’s okay to move it. This helps remove the neurological barrier that would otherwise stop their new range of motion. We usually do seated quad extensions or terminal knee extension using the floss band in the early stages of rehab.

After that, you’re helping the patient reinforce their ability to turn the quad back on. This could be a variation of wall drill, with the hands on the wall and fully extending the leg behind you, or this could be a marching drill. We have found that these drills have the biggest impact with our patients. But most importantly, the drills and the progressions should be dependent on the patient and their own pace. We hope this has helped you in prescribing the right drills for your ACL patients. Good luck.
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