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I recently had a discouraging case that came through the door.  Discouraging not to the patient, but to our profession.

The patient is a 46 y/o female s/p ACL reconstruction (allograft) 8 weeks prior.  She tore her ACL 4 weeks prior to surgery while jumping on a trampoline.  She initially went to physical therapy at another location (who did not get her in until 2 weeks order was written) and participated for 15 visits (3x/week for 5 weeks).

To make a long story short, she went back for a follow-up with her surgeon and he was immediately appalled and disgusted by her results.  He put her back on bilateral axillary crutches and locked her brace for all ambulation status.  He then referred her to our clinic.

Here are her objective measurements:

Inspection: Body habitus was mesomorphic (normal weight) without any significant distress (other than obvious discouraged look).  Arthroscopic portals were healed and not painful to touch or s/s of infection. She had apparent quadricep atrophy and measured a few (sorry don’t remember) centimeters difference compared bilaterally when measured circumferentially 3″ above superior pole of patella.  Patella mobility was hypomobile, especially in cephalic to caudal direction.

Pain level: Pain was very minimal at rest, 1-2/10 (0 to 10 scale) but went up to 5/10 (0 to 10 scale) peri-patella more inferiorly that ‘pulled’ down to middle third of anterior shank with active flexion.  Described as more of an ache/pull but no sharp pains.

Strength: I didn’t measure MMT per say but I did get her to perform a quad set (which she did not know what it was…I’ll get to this later) and I tried to ‘break’ it while she was in supine.  Very little force was needed and as expected, poor quadricep strength (I normally don’t grade ‘poor’, ‘fair’, ‘good’) but you get the point.

Gait: Stiff-leg, circumducted gait pattern with brace locked in full extension using bilateral axillary crutches.  Very little contact through involved limb, even at initial strike.

ROM: Active extension lag was 3 degrees and flexion was 60 degrees in sitting on edge of plinth and 80 degrees measured supine through a heel slide.  Passive range of motion was not a significant amount more and guarded into flexion, as expected.

All of these findings are below what we would expect at this time-frame, but ROM deficit kills me here. We all know to get full ROM s/p ACL reconstruction.  Strength will come.  So, I am appalled by the lack of range at 8 weeks out.

So as I am examining this patient, I am asking her what types of exercises/treatments she was getting from the past clinic.  She named a few before I just disgruntledly stopped her; which included wall squats, wobble-board, SLR flexion, heel slides and recumbent bike (which they recommended she buy one at home for $300…and she did).  No quad sets, no passive ROM, no hands-on at all.  On a positive note, the therapist was very nice and sweet says the patient.

Treatment:  Back to basics.  I put my hands on the knee. I provided some low to middle grade anterior to posterior mobilizations of the tibia on the femur as her knee was bent over a foam roll in supine.  I also passively flexed the knee but held my proximal hand just inferior to popliteal space and provided a posterior to anterior drive of the tibia with passive, then active knee flexion.  Nothing strenuous here, assessment of the joint led to treatment.  All of this maybe took 4-5 minutes.

P/A glide of tibia with passive knee flexion.
Knee oscillations (similar to heel slide but using a foam roll)
Quad set

All of this “felt good” to the patient and upon completion, she had 100 degrees of knee flexion supine (heel slide) and was able to dangle leg off of plinth fully (so at least 90 degrees).  She did not have the ‘pull’ down the anterior shank and pain level was minimal, just felt tight at end-range.  She and I were satisfied by a 20 to 30 degree improvement in ROM in just a short period of time.

I prescribed her quad sets (5″ hold) and knee oscillations on a foam roll. I unlocked the brace but kept her on the axillary crutches. I told her to hold off on the other exercises until the next visit.

I saw her the next day and she still had 100 degrees of flexion.  She is feeling better overall and ready to move on!  Extremely happy with the results and has even posted her success on facebook 🙂

The moral of this case is back to basics.  It is not intended to degrade or pick on another facility or approach. But, nothing fancy was performed here.  Not sure if a protocol was followed (which usually include the exercises she was prescribed) or just neglect. Back to quad sets, back to a hands-on approach, back to personal, individual care.  Who needs wall squats and wobble boards when the foundation is not set.

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