What has the Biggest Impact on Outcomes Following ACL Reconstruction Surgery?

Loss of knee extensionIt is no surprise that loss of motion is one of the biggest factors in patient satisfaction following ACL reconstruction surgery, specifically loss of knee extension.  In addition to the limitations in functional activities that occur with loss of knee extension, we have also discussed some of the risk factors of loss of motion following ACL reconstruction.

Loss of knee extension has a dramatic impact on gait, muscle activity, and normal tibiofemoral and patellofemoral arthrokinematics.

Imagine not being able to straighten your knee out.  You can’t lock out your knee for stability.  You naturally will shift your weight to the other extremity and overload your other knee, hip, and probably even your back.  Your quad and hamstring never get to shut off and relax.  Your patellar tendon will probably be on fire, and your patella will always be engaged and taking stress.

I can definitely see why patient satisfaction would be poor if you had long term loss of motion following ACL reconstruction!

Impact of Loss of Motion on the Development of Arthritis

In addition to poor patient satisfaction, recent research has shown that loss of motion following ACL reconstruction also results in the development of osteoarthritis.  In a recent study in AJSM, Shelbourne et al followed 780 patients for a mean of over 10 years.  They showed that of the group of patients that had normal motion on follow up examination, 29% exhibited signs of osteoarthritis on radiographs.  Conversely, 47% of the group that showed loss of motion had developed osteoarthritis.

This makes perfect sense as your arthrokinematics, center of rotation of the joint, and tibiofemoral and patellofemoral contact pressure will be altered.

How Much Loss of Extension is Significant?

More importantly, the authors also showed that even a loss of 3-5 degrees of motion had a significant impact on both patient satisfaction and the development of early arthritis.  Those subjectives that exhibited greater than a 5 degree loss of motion had an even more dramatic impact.

According to DeCarlo and Sell, the average amount of knee extension in healthy individuals is 5 degrees of hyperextension, with 95% of individuals demonstrating some amount of hyperextension in the knee.

Taking this into consideration, we should challenge the common belief that 0 degrees of knee extension is “normal.”  Individuals with 5 degrees of knee hyperextension that only restored their knee to 0 degrees of extension after ACL reconstruction surgery have a significantly greater chance of developing early osteoarthritis.

Clinical Implications

Based on these recent studies, there are bunch of clinical implications that we should all consider.  Here are just a few that I thought of right away:

  • Timing of ACL reconstruction surgery and pre-operative rehabilitation is important to settle down the knee, reduce swelling, and most importantly restore range of motion.
  • Knee extension should be restored as soon as possible after surgery, and should be one of the focuses of the initial postoperative phase
  • Even a small 3-5 degree loss of either extension of flexion range of motion has a significant impact
  • Most patients will have a certain degree of hyperextension, restoring a person to 0 degrees of knee extension is likely not enough
  • For those training post-ACL rehab clients, keep this in mind if the individual does not have full motion.  Advancing to exercises with high tibiofemoral and patellofemoral compressive and sheer forces before achieving full knee motion should be performed with caution.
  • Each patient should be assessed individually and range of motion should be restored to their unique assessment
This information also shows the importance of skilled therapy following ACL reconstruction, despite some of the studies that may show that home exercise is equally as effective.  If loss of the motion has the biggest impact on outcomes following ACL reconstruction, the development of osteoarthritis, and the subsequent health care costs, this strengthens the need for skilled manual therapy during the postopertaive rehabilitation process.

In regard to what to do with the tight person, I’ll work on a future post that discusses how I assess and treat loss of knee extension range of motion, but in the meantime I would love to hear what you think about this information and what you do with these patients.

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35 Responses to “What has the Biggest Impact on Outcomes Following ACL Reconstruction Surgery?”

  1. Great post Mike! That’s why ther ex is not enough and manual treatments, plus assessment is important. Especially to get back the PROM which is supposed to be greater than, and not equal to AROM.

  2. Exactly, the couple of articles in the past that have shown home exercises are equally as effective as skilled therapy following ACL reconstruction have many flaws. I think this is a great point Erson, thx!

  3. just what % of post ACL pt’s reach the pre-injury ROM beyond 0 degrees of extension. Isn’t there a self limiting reflex response of the individual not to go into the “red zone” so to speak, of challenging the ACL’s tautness. It seems that it is common to be 5 degrees less ( 0 degrees) than an uninvolved knee that is +5 degrees

    • Joel, although it seems common to have a loss of motion, that doesn’t necessarily mean it is best! I personally haven’t had this self limited reflex you mention. I bet the key is to:

      1) do everything you can so you dont lose the motion and then have to aggressively restore and trigger that “reflex”

      2) Gradually, but progressively get that motion back

      If you take your time getting there, perhaps that prevents that self limitation.

  4. Great post, Mike…couldn’t agree more. I might add that restoring quad activation/NM control has proven to be just as essential. Restoring normalized ROM is the 1st step…while assuring the patient has adequate control of the newly gained ROM is a close 2nd. If they don’t have the quad control…chances are they won’t be able to control TKE at midstance and thus resorting back to a flexed gait.

  5. Coming back from an ACL myself I have found it regaining the flexibility in my Hip Flexors, Glutes and Quads has helped me get flexion similar to my healthy leg.

    I also Asked my PT the reason they stopped my extension at 0deg and his reasoning was that working towards hyperextension( beyond 0 will affect the tightness of the graft. Have You heard that too?

  6. I had my first job in physical therapy working for Dr. Richard Steadman in Vail, Colorado…basically the ACL capital of the world. Extension is always goal #1, meant to be achieved immediately post op. Goal #2 is being able achieve full extension with a quad isometric contraction. If your unaffected knee hyper-extends 5 degrees then you post-op knee needs to get to 5 degrees of hyper-extension. Your quad needs to be strong enough to actively extend to it’s fully extended position (+5 degrees).

    A high percentage of my clientele continues to be post-op ACL patients, and hardly anyone has an issue regaining full extension (and subsequently a very successful outcome) due to proper pt education. I give each patient of mine a list of 4 goals that MUST be achieved by 6 weeks, which is the typical ‘healing phase’ post ACL.
    1. Full Extension
    2. Perfect quad set/able to do SLR without ANY lag–TONS of repetitions as pt progresses, try to make every rep perfect.
    3. Flexion to at least 120 degrees. 120 typically comes within the first 10-14 days, the remaining flexion returns very easily.
    4. Reduce pain, swelling, inflammation. Urging people to not over-do their activity, not taking stairs normally for 4-6 wks, ice and elevate regularly, etc. Swelling is the biggest enemy, it inhibits your quad, limits your ROM, and leads to all the issues pt’s have post-op.

    Getting the patient started on the right foot paves the way for a successful outcome. Of course post-op ACL pt’s fear hyper-extending their knee, but ACL pre-hab, and post-op PT within 3-5 days helps get good quad control early on, and pt’s benefit greatly from that.

    • Hi Jeff. I’m 6 weeks post surgery and I still don’t have full extension. Do I still have a chance at getting it back? Please let me know how if possible, thanks!

      Also there is still some swelling present in the knee, could that be why I havnt got it back yet despite try quite aggressively especially during the last week?

      Please let me know:)

  7. Mike i am training a college football lineman this summer who had Acl/Lcl reconstruction and meniscal repair an achilles allograft acl and semi-tendonosis lcl allograft. He has another 5 deg to reach 0 ext and his flexion is just over 90 deg. His school trainer told me to do all closed chain exercises along with the at home brace he wears at night and progress him as i see fit. Mike does the multiple surgeries change the ext/flex restoration time frame. Or should the rehab be more agressive. Any help would be greatly apreciated thanks

  8. Question – isn’t knee hyperextension often a compensation for poor ankle mobility in dorsiflexion? I’d be concerned about working towards hyperextension in the affected leg unless I had evaluated the unaffected leg for limitations in dorsiflexion first. I’m a S&C coach, not a PT, so my understand of this is limited! Please let me know your thoughts.

    • Sure, but one could argue chicken or the egg. To me, I have seen many collagen lax people that have a lot of recurvatum. Think about it, if they are loose and sit back in knee extension, how could they dorsiflex their foot? The stand in a certain degree of plantar flexion. I would say that is more common but heck anything is possible. I dont see a lot of people with tight DF that causes excessive hyperextension of the knee. They probably had that hyperextension to begin with.

  9. Hey Mike great post. What do you think about using a theraband looped underneath the heel to force the knee into a little hyper-extension while performing a quad set 2-3 weeks after surgery?

    • Chris, if that isn’t too dynamic that sounds fine. You do need to have a little bit of caution of forced hyperextension beyond what is “normal” (See above) for the patient, as this could strain the ACL.

      I try to prevent the loss of motion as much as possible so that I dont have to force it too much.

  10. Great post Mike. but after surgery, shouldn’t the knee be in a recovery state without too much stress or weight on it for an amount of time. The constant slight bend and straightening of the knee should support the knee’s abilty to be moved without the fear of immobilization of the knee. which tools should be used in the extension recovery stage of the knee?

  11. Hi Mike
    I am currently 3 weeks post op for a revision ACL using the patellar tendon graft after I unfortunately tore my 2.5 year old hamstring graft. My recovery is going well and I have full extension and I get close to 1cm lift off heel to floor while laying down and contracting my quads hard. My unaffected leg (and the operated side pre injury) have a lot of hyperextension, probably 5cm lift. Should I be aiming for equality here? My PT and Surgeon of course get the final word but I am very interested to hear your thoughts on how much hyperextension should be limited in this kind of case.

  12. Hi mike, I’m 45 and snapped my acl and high grade tear of my mcl playing netball. I did not have good rom prior to surgery. Extension wasnt measured but my knee was definitely off the ground, and my flexion was only about 80 after a pt session. I had recon 5 weeks after the initial injury and I am now 5 days post op. I still have heaps of.pain. I am doing all the physio exercises but am worried about my Rom. I have been lying on the couch reading everything I can but everything says u should have normal Rom prior to surgery for a positive outcome. I’d appreciate any advice. I’m really concerned. Thanks Kylie.

  13. Hey Mike, I had multiple ligament surgery in November 2008 (acl, mcl and lcl- allografts were used for all).
    By September 2010 I was 8 degrees from 0 exstention on my right leg and had about 140 degrees flexion as compared to my left leg that has 5 degrees hyperexstention and 155 degrees flexion.

    Now, in November 2010 I retore my acl and just recently (July 31st 2012) I decided to get the acl surgery done (allograft again). So now I am 8 weeks post op and I have been able to get 0 degrees exstention in my right leg and about 145-147 degrees flexion in my right leg. Is there any way I can make my exstention and flexion in my right equal to my left? Or is that not a possibility because of all the surgeries I have had…and build up of scar tissue?
    Any advice would be appreciated.

    • Jesse, the longer it is from surgery, the harder it is to achieve, but sounds like you are doing much better after the 2nd time around. You may stil benefit from some skilled manual therapy. Good luck.

  14. Hello Mike,
    Somewhat embarrased to ask but its been 18 months since my ACL surgery and yet I can’t get full extension. Sometimes i feel like theres something in my knee blocking it from full extension. Is it possible that there may be fluid in my knee? I sometimes have a friend put his weight on my knee to force it down. Is that a good idea? Any exercises that may help me get full extension. Any advise is much appreciated.

  15. Had your ACL reconstructed?

    I am doing a Master’s reseach project on ACL reconstruction and want to know about your experiences about rehabilitation, and getting back in the game.

    Please visit http://fluidsurveys.com/s/returntosport/ to participate in a short web survey. Participation involves answering 19 on-line questions about your activity level, your experience surrounding the process of rehabilitation after ACL reconstruction, and your decisions surrounding returning to sport. The questionnaire will take 5-10 minutes to complete, is completely anonymous, and will have no influence on your medical care. This study has received approval from Hamilton Integrated Research Ethics Board.

    Jacquie Minnes PT
    School of Rehabilitation Science
    McMaster University

  16. Hi Mike,Tomorrow I will be 10 weeks post op from my ACL reconstruction surgery using hamstring tendon.

    My flexion is ok but I am having problem with extension. I can extend my knee till 0 degrees but have not yet achieved that -5 degree extension or as much as my normal leg can extend.

    I have read it on many websites that full extension is very critical to healing. At one site I read that if it is not achieved in one month then it can neve be achieved. Somewhere else I read that after 6 weeks it is very difficult to achieve it. I m very much in fear due to this. But my phisio seems to take things very easy.

    Q1. But my first question is that does full knee extension (that I keep on reading about everywhere) mean that 0 degree extension that I have already achieved or does it mean that negative extension of -5 degrees that I have not yet achieved?

    Q2. And if it means that -5 degree extension then is there any chance that I might still be able to achieve it since the websites say it is difficult to achieve at later stages?

    Q3. Last question is that is it okay to be changing your phisio just 5 weeks post op?
    Please Help!

  17. Hello Mike…
    here I go 3 months post acl reconstruction surgery by hamstring tendon auto graft.I got full extension and bending in time. But from past 15 days I got pain in my hip (same leg). I stopped exercises but this not helped fully. Sleeping with back becomes difficult.what can be the reason for this ? how I can get rid of this hip pain?

  18. BACKGROUND:

    I am 44 years old. I am female. I was born with a 5% hyperextension I guess deformity. It seems to run on my mother’s mother’s side of the family b/c my mother has it ~4-5%, I have it, and my uncle has it 4-5%, and so do both of my nieces4-5% and I believe my son has a small amount, maybe 1%. Oh yeah, and one of my sisters has it bad too, 5%. Whatever this is and despite the fact that I have a lateral mensicus tear in my right knee, which I believe occurred when I was a teen ager from playing high school sports. Then at 18 I was in a car accident and broke my right femur (1987). Was a very typical injury w/classical treatment; muscle lengthening then rod insertion; removal occurred in 1989. However, I don’t think the accident or the lateral tear injury has anything to do w/me having to be extra careful about “knee impaction.” I feel like an old lady for christ sakes!!! I can’t have this. I am terribly depressed. I have carpal tunnels in both hands, and the left hand from the elbow. That’s a pain in the ass in of itself (feels like my funny bone is being smacked around alll the time. Furthermore, I am short 5’1” so I have a hard time “hitting my feet to the floor” when I am positioned in a chair. I don’t know how one can even begin to think of how to position themselves with this impediment!!! There is a respectable 5% of the population that is my height or shorter that deserves the respect of being able to hit their feet to the floor while having to sit in a chiar all day long at work. Can you even begin to imagine the pressure that goes to my lower back? Christ sake, I got so weak one time for being stuck in the home for two years (just this past two years, too), that I couldn’t even sit up in a chair anymore. Nope! I went from 126lbs to at least 155Ibs. So, bad that my fat on my stomach “sags.” What the hell is that? Yeah, my husband had it when I met him but I thought it was b/c that was how he just was b/c he was overweight. Now, I am thinking it has to do more with age. I was 155ibs once before for a very short while in my twenties and never saw this “hanging sagging type of fat.” Before, it either just rolled over, or stuck out like pregnancy. Now, it hangs. Got so bad that it “bent my vertical c-section scar” and caused bleeding there for a while. So, for two years I was in a depressed state and very rarely got out of bed b/c there was no where else in the house to go b/c the house was so small. We live in a rural cold area so it was just as so, so I thought. Well, literally almost a year ago was when I hit my high in weight. I’ve been trying to lose it ever sense. I can’t beleive how hard it is to lose as soon as you hit over 40!!!! I’m like another fricken human being? Who done this shit to me? Cuz, this wouldnt’ of ever happened to me under 40, and people can blame me all they want and that is fine but I honestly got to say to you that I never saw it coming!!!! Sure, the staying bed and getting fat, I done that before, and did NOT have this hell of a time trying to recover.

    ISSUE:

    Well, one of the main problems is the problem I am haivng with my hyperextended knees of 5% feelign like they can’t withstand even a small jump from a step. I know that if I try to do that that myt weight which is only 144obs now (I’ve been working out….not as much as I should but at least I am doing it now) will be all put onto my knee caps and because I can’t extend them all the way back because obviously our legs don’t go well that way, I get shooting pain, and not the good kind of pain either in my knee caps telling the load is too much. Problem is that I also had this happening when I was around 126lbs too. So, I’m wondering if it has something to do with age. One thing for sure is that I found that I was only 1/3 the strength, I am not kidding 1/3rd the strength I was in my teens and twenties. Where I could do 60ibs of leg extensions, i can onlly do 20obs. I know this has to have somethihg to do with it doesn’t it? I have to strengthen up my muscle around my knees don’t I? Is there anything else that can be done? What do they do for kids today that have this 5% deformity in being hyperextended about the knee? I know it can’t be good on them as they age like I am now doing.

  19. why has the pendulum swung from 4 months post-op expedited return to play.. to now more conservative 9 months?

    • Lots of factors. I dont think 4 months return to play was ever popular. Perhaps it was done, but not overwhelmingly popular. Part of this was the fact that basic science studies showed that healing of the graft was similar around 3 months as it was 6 months, so why wait? But, the knee is rarely “ready” at 4 months.

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