By Guest Blogger Lauren Calamari, PT, DPT
The early days of rehab after ACL surgery are not glamorous. However, they are vitally important for setting up long-term success. Regaining knee range of motion is one of the first post-operative goals. While knee flexion (bending) is important, regaining knee extension (straightening) early on is a key factor for successful recovery. In fact, research shows us that failing to do so can put you at risk for negative long-term outcomes1,2,3. It is important to note that not all surgeries are the same, and many people have additional injuries that are also addressed during surgery. This can change the overall post-operative precautions, including range of motion, so always consult with your surgeon and/or physical therapist about what is best for your knee.
Achieving terminal knee extension (getting all the way to your knees end range of straightening motion) is important for several reasons. It is necessary to have a normal gait (walking) pattern once you can begin walking. It can also help to reduce post-operative swelling. Reducing swelling and attaining full extension allows your quadriceps (thigh) muscles to activate properly. In fact, swelling can “shut down” or inhibit the muscles surrounding your knee. This is called quad inhibition. In turn, quad inhibition will make it harder to diminish lingering swelling. You can see how this can become a vicious cycle! The bottom line is, regaining terminal knee extension as quickly as possible will help lessen these early challenges. Early quad activation will allow you to strengthen your quads adequately as you advance through your rehab process. Sufficient quad strength is essential for a safe return to your prior activity, no matter what that is. Strong quads give your knee stability and can help prevent secondary knee pain as you progress.
You can see why emphasizing knee extension early on is so important! Unfortunately, the first days and weeks following surgery can be exhausting and overwhelming, which can make accomplishing this goal tough. People often feel compelled to rest with their knee slightly bent or sit with a pillow under their knee. While this is more comfortable, it will make knee extension more difficult. During this time, it is easier to focus on a few simple tasks vs. a long list of exercises. So, here are a few simple extension exercises to focus on, which most people can perform right away:
- Heel Prop: Sit with your leg out in front of you and prop your heel on an elevated surface (this could be pillows, the arm of the couch, or the coffee table). Make sure only your heel is on the propped surface and there is space underneath your knee for it to fully straighten – the more elevated your leg is, the better (elevation also helps decrease swelling). Try to relax and let gravity push your knee down.
Try to tolerate this a couple minutes at a time. Over time, work up to 10 minutes of propping, 5 times per day.
- (Assisted) Heel Pop: Not to be confused with the heel prop. This will help with end range extension and quad activation. Sit with your leg out in front of you on a firm, flat surface. Loop a non-stretchy strap (dog leash, towel, fitted sheet will work) around the bottom of your foot. Gently pull on the strap to lift your heel off the ground while trying to squeeze your quad and push your knee down.
You might have to work up to these. Try 10+ squeezes at a time, holding each squeeze/heel pop for at least 5 seconds. Once able, do this several times per day following the heel prop.
- Quad Set: Sit on a flat, firm surface with your leg out in front of you. Squeeze your quad while trying to push the back of your knee down toward the surface. This addresses quad activation, which can be very challenging at first. Sometimes it helps to practice on your other leg!
Try 20+ squeezes at a time, holding each squeeze for at least 3 seconds. It is good to do this right after you finish the heel prop & heel pop.
Performing these exercises is an excellent way to work toward achieving full knee extension after ACL surgery. I encourage everyone to work with a trusted, experienced physical therapist throughout their recovery process, and always consult their surgeon before performing any independent exercise. However, doing these on your own as part of a home exercise program will be an important part of the early rehab process, and will ultimately set you up for long-term success!
Disclaimer: Please consult your physician or health professional before engaging in any physical activity and stop if you experience pain or discomfort.
About Lauren Calamari, PT, DPT
Lauren graduated from the Medical University of South Carolina with her Doctor of Physical Therapy. She earned her undergraduate degree in Exercise and Sport Science from the University of North Carolina at Chapel Hill. She has experience treating middle school, high school, and college athletes, as well as active adults of all ages. Lauren currently works in an outpatient physical therapy clinic specializing in sports-specific treatment in Baltimore, MD. Her other professional interests include writing, education, coaching, and management.
Sources:
- Delaloye JR, Murar J, Sánchez MG, et al. How to Rapidly Abolish Knee Extension Deficit After Injury or Surgery: A Practice-Changing Video Pearl From the Scientific Anterior Cruciate Ligament Network International (SANTI) Study Group. Arthrosc Tech. 2018;7(6):e601-e605. Published 2018 May 7. doi:10.1016/j.eats.2018.02.006
- Delaloye J-R, Murar J, Vieira TD, et al. Knee Extension Deficit in the Early Postoperative Period Predisposes to Cyclops Syndrome After Anterior Cruciate Ligament Reconstruction: A Risk Factor Analysis in 3633 Patients From the SANTI Study Group Database. The American Journal of Sports Medicine. 2020;48(3):565-572. doi:10.1177/0363546519897064
- Shelbourne KD, Gray T. Minimum 10-year results after anterior cruciate ligament reconstruction: how the loss of normal knee motion compounds other factors related to the development of osteoarthritis after surgery. Am J Sports Med. 2009;37(3):471-480. doi:10.1177/0363546508326709
Guest blog by Dr. Willie Manteris
If you are considering starting running and are a beginner or have been inactive for a good while, some simple tips could help a great deal for your success. First of all, I applaud your decision to run. It is a wonderful exercise/sport/meditation that can be done almost anywhere, anytime, and with a bare minimum of equipment. The benefits of running are many and range everywhere from physical fitness, mental health, emotional well-being, to social interaction, and on and on.
Different fitness levels, goals, and natural abilities will greatly influence your approach to running. But the basic principles are the same for everyone. For that reason, I would suggest starting with a good book that explains the basics of running and gives you an understanding of the fundamentals. Incidentally, I would stay away from running magazines in the beginning because they throw out many different training techniques and ideas with each issue that can confuse a beginner. The basic principles are rather stable.
The next step would be to begin to prepare your body for your new endeavor. Learning stretching techniques for flexibility and some mild weight or strength training geared specifically to running will help prepare your body. A few weeks of these before starting your running, and continuing during your running, will help keep you injury free.
Then you will want to get running shoes that are properly fitted and appropriate for you. It is well worth the extra money to have an experienced professional help you select the type best for you as opposed to buying online or off the shelf somewhere. Running stores are specifically geared for this.
When you are ready to go outside and do your first run (and I always prefer outside in nature whenever possible), the best way to acclimate your body without over-stressing is to start by alternating walk/run. Of course, do your stretches first, then warm up by doing a brisk walk and eventually move into a slow jog. You might start out alternating as little as 20 second intervals each walk and run, and then extend them as your body adjusts. The key here is: be patient! The sedentary lifestyle that most of us lead does not prepare us for this type of exertion. It will take time for your body to regain its natural vigor. And the rewards will be many.
Another point that I would stress at the beginning is to think about proper running form. A smooth, graceful stride with correct foot strike and body posture can make all the difference between building your body up or breaking it down over time and miles. If you watch other runners you will soon see different styles and begin to sense which are efficient and which destructive. Again, an internet search on proper running form can give you this information.
As you progress, your cardiovascular system will most likely improve faster than your musculoskeletal system. Chances are, as your fitness improves, you will soon want to go faster and farther than your body can accommodate. This is where so many running injuries occur. Keep in mind that running performance is a long-term project and is progressive in nature. Done correctly, the common thought for beginners is that they want to go faster and farther. Take your time. You can add intensity and distance later and may amaze yourself at what you can do. But time is the key factor. For long distance running the saying is: learn to run far, then learn to run fast, then learn to run far fast. A rule of thumb is not to increase your milage by more than 10% a week. But it does not have to be competitive. We are not paid professionals after all.
From this simple beginning there are many options available as you progress. Heart rate monitors are very helpful if you want to do some serious training or like to monitor yourself. Proper diet, fuel, fluids, electrolytes, rest, are all factors to consider as you get more advanced. There are a multitude of different training programs available for various goals and styles. One thing I particularly liked was the Swedish form called “fartlek running.” It means “speed play” and basically means running at different speeds for different intervals, as your body tells you. It is the closest thing that I found to the pure joy of running I remembered as a child.
There are, of course, many, many more details to running, but I think it best to keep it simple at this point. I whole-heartedly encourage you to take that first step and try it out. It could mean a substantial boost to your well-being for the rest of your life, and even a longer life for that matter.
Final words of advice: be patient and have fun. It would be very difficult to maintain if it isn’t enjoyable for you. Make it enjoyable, and good luck.
Reminder: Please consult your physician or health professional before engaging in any physical activity and stop if you experience pain or discomfort.
About Dr. Willie Manteris
Dr. Willie Manteris is a retired dentist living outside of Pittsburgh, PA. He began running at 47 years of age and has many marathons, triathlons, and century bike rides under his belt. He will be 72 years old next month and is still running, biking, and weight training while having fun.
Cover photo credit: Kampus Production
It’s not uncommon when I tell friends that I have a physical therapy app (to help patients do their exercises) that these friends inquire if I could recommend exercises for them. Recently, I was asked if I could recommend exercises for a friend who injured his Achilles Tendon while playing racquetball. He had recovered from his injury and wanted to start running again but discovered that his push-off strength was imbalanced. Not being a physical therapist, I don’t prescribe exercises but was able to point him towards Dr. Leada Malek’s recent Instagram post where she demonstrates several Achilles Tendon exercises. My friend was able to find these exercises in PT-Helper Pro and create his own unique exercise program to build up his calf strength.
Some exercises recommended by Dr. Malek are:
Eccentric Heel Raise – 2 Up 1 Down: Stand facing a wall with your feet shoulder width apart. Place your hands on the wall for support. Raise both heels simultaneously. Transfer your weight to one leg and raise the other leg while keeping your heel raised. Hold. Slowly lower your heel back to the ground. Lower your raised foot. Repeat.
Weighted Seated Heel Raise: Sit on a chair and place a weight on top of your thigh of your affected leg. Raise your heel off the floor. Hold. Lower your heel back to the ground. Repeat.
Weighted Seated Heel Raise with Riser Block: Sit on a chair and put a riser block under your affected forefoot so that your heel is below the level of the block. Place a weight on top of your thigh of your affected leg. Raise your heel above the level of the block. Hold. Lower your heel so that it is below the level of the block. Repeat.
Squat with Heel Raise: Stand with proper form with your feet shoulder width apart. Bend your knees while lowering your hips to go into a squat position. Holding the squat position, raise both heels off the floor. Hold. Lower both heels back to the ground while staying in the squat position. Repeat.
Reverse Lunge to Triple Extension: From a standing position with feet hip width apart, take a large step backward with one leg as you bend both knees to go into a lunge position. Your front knee should remain above your ankle (for the leg that didn’t move). Do not allow your knee to move past your toes on your stationary foot. Push off with your rear foot as your rise up and bring your rear leg up in front of you. Simultaneously raise your heel of your front foot. Return to the lunge position. Repeat.
In addition to the exercises listed above, we have many more exercises available to help you achieve your recovery or fitness goals.
Reminder: Please consult your physician or health professional before engaging in any physical activity and stop if you experience pain or discomfort.