ACL Recon Extension Question/Concern

by Paul
(NY)

29 yr old, fairly active male. I had ACL Reconstruction (hamstring graft) on 9-18-2008. I began PT on 9-26-08 but had been doing home exercises since 2 days post op.


I am having an issue with leg extension. It seems to settle around 5 degrees. My PT has been very aggressively stretching...I mean with an assistant holding my waist down and then stretching my leg. This has been extremely painful but she thinks it is helping. After stretching,the extension is around 2 degrees. I do prone hangs with ankle weights 1-2 times daily, along with numerous other stretches.

Initially my PT said she believed my issue was extremely tight hamstrings. I saw my surgeon on 10-13 and he mentioned something about scar tissue but did not display too much concern. He did say to keep "stretching like crazy or I will not be able to play sports again"

Besides this issue I have to say everything is great....my flexion is really not an issue, my muscles have responded well and I can do all the leg press, leg lifts, hip abductions, etc they ask me to do. I walk/sleep and essentially get around pain free....except for the slightest limp due to the extension.

I know this was long but I guess my question is, do you think that it is too late for full extension to come back? Any other ideas what my underlying issue could be, and things i could try? I am just disappointed to go through all this and come out with diminished extension and now not be able to do things i could actually do pre surgery.

Thanks

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Nov 30, 2008
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ACL Hamstring Recon with 10 flexion
by: Lucy

So about 5 years ago I had an ACL Repair with the Hamstring, and I was having similar problems. I only got to about 10 extenstion. My PT was an idiot and told his assistant before entering my curtain, that God helps those who help themselves, and you will see your first person cry. To my surprise they both walked into my curtain. What they tried to do was force me to full extention by putting his weight on my knee. Yes very painful, but I would not give them the satisfaction of seeing me cry. I was very unsupervised during PT. At any rate when PT was done and I was coming on my 1 year Post Op and talked with my Ortho regarding this, all he said was see you back in 3 years. I spoke with my primary and told him something was not right. I went to a different Ortho who explained things so much better.

He said that when you graft the hamstring tendon, you are cutting it out of the body and there is no blood flow. Because there is no blood flow the tendon dies and shrinks. They make what we call a notch plasty for the grafted tendon to go through. Once they put it back in and the blood starts to flow...it gets bigger. If the notch plasty is not adequate enough for the new tendon, you will not have a full extension. That was my case. I went back to surgery and he fixed the notch and made it bigger. Within a week and a half I was doing GREAT. Something to check into. I have full extension now. Good Luck

Oct 22, 2008
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extension lag
by: Bart - SII

It isn't too late to regain your extension, but the longer you go without it, the harder it will be to get it back - you have about a 6-8 week window after surgery, then it becomes very difficult.

There are usually two things that will restrict extension after an ACL reconstruction. Excessive scarring and loss of normal joint arthrokinematics. Tight hamstrings generally don't cause an extension loss passively.

You can develop scarring in the knee that will restrict normal motion of the joint - usually this is more common with patellar tendon grafts, but it can happen with hamstring grafts as well. Friction massage around your incision site and mobilization of the patella can sometimes help with this.

You can also develop scarring around the graft inside the joint - sometimes called a cyclops lesion - that is something that can only be fixed surgically.

The loss of normal joint arthrokinematics is very common, especially if full passive extension isn't there within the first few days after surgery.

When you bend and extend your knee, the bones must be able to slide, glide, and roll against each other. If this doesn't happen, then you cannot gain full range of motion. Tightness of the joint capsule can cause a loss of accessory motion and this will restrict extension.

While stretching your knee like you describe can help gain a few degrees, but it doesn't restore the normal kinematics of the joint. Joint mobilizations, specifically posterior femoral glides, will help to restore that normal motion.

Many clinicians are a little tentative to mobilizations after an ACL reconstruction because they are afraid of hurting the graft, but properly done, they are a safe and effective way to restore normal extension. I have used them, in varying grades of intensity, with every single ACL patient I have ever treated. They are an essential part of the rehab process.

I would discuss this with your PT and talk with them. Joint mobs can be painful, but shouldn't be any worse, less painful in fact, than what they have been doing up to this point.

Bart

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