Easily Restore Knee Extension After Injury or Surgery
I spent many, many, many days of physical therapy in tears with the PT cranking on my knee, trying to force knee extension and flexion after surgery. It was traumatizing to say the least, and now I know it didn't need to be like that. After rehabbing 3 surgeries in high school and college and forcing the range of motion, by the time I had my 4th surgery as a sports healthcare professional, I knew better and was able to quickly and easily improve my knee extension- no force, no tears, minimal effort.
In this podcast episode, I share my top techniques to quickly restore knee range of motion after injury or surgery that don't require old school forceful techniques but work with the body to restore the joint arthokinematics and osteokineamtics quickly and in a way that sticks from treatment to treatment, so you don't have to endlessly repeat the techniques in every rehab session.
Resources mentioned in this episode:
Swelling Reduction Protocol That Works Like Magic Podcast Episode: https://www.movementrev.com/podcast/seasion-1-episode-3-swelling-reduction-protocol
Unlocking the Fibula Podcast Episode: https://www.movementrev.com/podcast/season-1-episode-8-unlocking-the-fibula
Using Bone Rhythms to Restore Knee Extension: https://youtu.be/cSAh46t7nnk
Knee Distraction: https://www.instagram.com/reel/CtuC3oIPLYv/
Articularis Genu self massage: https://youtu.be/NXNhjwI9ypM
Articularis Genu mobilization: https://www.instagram.com/reel/CZxjJTelOw7/
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Hey there and welcome. I'm Anna Hartman and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone. Even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello. Hello. Welcome back to another episode of the Unreal Results Podcast. So this week I was going to record an episode on grief and. I still probably will, but, um, first I'm gonna record an episode about the knee. I got a question on Instagram. Um, thank you for submitted questions about, one of the questions was how to get.
Full knee extension after a meniscus injury. And I started to respond on Instagram and the stories, and I was like, I have a lot to say on this. And you know what, this is gonna have to be multiple posts and honestly, it should be a podcast. And so that's, that's where I'm at today. Um, Ironically too, right after I got that question, um, I had an athlete come to me for some knee pain and his knee was so stiff and lacking so much knee extension, um, that I was like, oh, I, ironic, ironic how that comes up like that.
So, um, that's what we're gonna talk about today. Uh, part of the reason I think I feel so strongly about this too, is because I struggled with getting full knee extension back after my first couple surgeries. Um, I don't, well, honestly, let's, let me actually think about that. My first surgery was in, I. Hmm, 1996, I think, which is crazy that that is like 26 years ago.
But, um, that was my first surgery and I went in for, um, meniscus, uh, repair, um, not a repair, a meniscus removal. Um, and uh, so it was a scope and when I was. In surgery, they saw that I had torn my acl. So a little backstory, like right before that surgery I had re-injured my knee and they, the insurance company wouldn't approve another MRI cuz I had just had one.
And so, um, they were going in surgery kind of blind and so, Go in surgery, they, you know, trimmed up the meniscus, obviously at that point was not prepared to repair my acl. And so after surgery the doctor was like, Hey, bad news. You got a, you have a ACL tear and, uh, so y'all need to have another surgery. If you wanna repair, repair it.
Excuse me, if you wanna repair it. And also, you know, fuck, fuck this guy. He also said, by the way, you're to a 16 year old, by the way, your knee looks like, um, a knee of an old unlucky running back. What, which, what does that even mean? And then also no, it didn't. Like, yeah, I had a little meniscus tear and a, um, And then a torn acl.
But I didn't have a ton of arthritis. I'm not really sure why he told me that, but that was like a bad thing to tell. And the way my sister heard it was like, oh my gosh. She goes, I remember coming out surgery. And she's like, Anna, you're gonna be lucky if you ever walk again. And I was, and then I burst into tears cuz I was like, post medicine recovery room.
And I was like, what? Anyways, it was traumatic, traumatic surgery. Anyways. I don't actually remember a ton about rehab after that first surgery because I think I was just like, well, I gotta get another one. So I honestly am not a hundred percent sure if I had full knee extension. I like full range of motion, full knee extension after that first original surgery.
Um, I waited about a year, um, not really a hundred percent sure why we waited that long to repair my acl, other than back then the doctor was like, well, you could potentially not have surgery. But anyways, so then the following year, 1997, I had, uh, ACL surgery and back then it was like a open, a very open procedure.
So I have a very long scar. Looks like I have a knee replacement, but it was a open procedure, patella tendon graft, had the surgery. Great. Um, did the rehab and during the rehab, oh my gosh, so painful,
right? So. If maybe you've experienced it. I hope people are not still experiencing this type of rehab, but I have a feeling that it might still be happening. But I had a hard time getting my extension back and it was a very painful experience. In fact, actually I had a hard time getting my flexion back too.
Um, just range of motion in general, which for someone who is like hyper mobile flexy person, that was surprising. And um, so I mean, it was like, Every day of physical therapy was like tears of pain. They had like strapped me to the table and like, were forcing my range of motion. Ugh. It's so painful to think about.
And um, you know, I finally, I left. I left physical therapy and I, I still was lacking full extension and, um, and especially into hyperextension cuz my other leg, you know, was hyperextending into like 10 degrees of knee extension. And so, you know, hindsight, now I know why that happened. The part of the reason that was happening is because my graph placement was wrong.
Um, like many. Acls done in the nineties. Um, the graft placement was wrong and had then has since failed. And so I actually still have a torn ACL on that side. But, um, you know, so it makes sense why I wasn't able to get full knee extension and full flexion very easily because, The arthrokinematics of the joint were totally thrown off.
So, but anyways, um, it's something that I really didn't have for a long time. It wasn't until years later in college, um, in one of my first athletic training classes that. Someone did like, um, I wanna say that the professor did like strain, counter strain or some sort of actually very gentle, more osteopathic, osteopathic type technique.
Specifically on, um, the rotational mechanics around the knee that I gained my knee extension back and, um, I remember bursting into tears of joy and relief because it, I hadn't had it for so long and that was so much easier than the process to get it when I was in high school. And, um, Unfortunately after that it just didn't stick.
And then, you know, I tore my other ACL and that actually that acl, I didn't really have a problem. I didn't get, have a problem getting my full extension. I didn't have a problem getting my full flexion. I do remember it still not being so, um, Comfortable. I remember doing like prone knee extension holds, hangs with the, you know, like a 10 pound weight on the back of my leg, like still a little old school in terms of getting the range of motion.
But I was able to get it and keep it. And then, um, when I was in grad school working at Athlete's Performance, when I started shrink training, um, that is what finally got me my extension back. In my original, my left knee, my, um, originally that had such a hard time. And so that was, um, a cool experience because it was eye-opening to the importance of like strength and safety in order to, um, Have full terminal knee extension and control.
Um, but then it was something that I continued to struggle with on and off. And again, now that I have the information that my acls re torn, it makes sense because my arthrokinematics easily get off in that knee and limit both my extension and flexion quite a bit, as well as drive some underlying swelling.
So, So this is why I feel so strongly about this is probably because of my history of what an uncomfortable experience that was, but then also because in my 20 plus year career, I've helped so many athletes. Get their full knee extension after surgery and get their full knee extension after surgery.
Sometimes like years later. There's so many athletes that would come to see us at Athletes' Performance now EXOS and you know, they had, would've had like a c l surgery in college and then their, their in during their years as a professional knee, they're still super stiff into knee extension. And so we got really good, I got really good at restoring mobility to the knee and understanding.
Standing, like all the components of it and then. Now having added in a lot of the osteopathic work becomes even easier. And so I wanna share all of these tricks because I don't want any more people having to do prone knee hangs or being, you know, strapped the table and forcefully manipulated into knee extension and knee flexion anymore because there is a better way.
So that's what we're gonna talk about. So first of all, yes, when it does come to restoring knee range of motion, especially after injury or after surgery, making sure you're. Treating the swelling and the you're getting the swelling out of there is really important. When there is fluid in the joint, it's going to limit the mobility in both flexion and extension when there is fluid in the joint and it doesn't take very much fluid at at all, you have a art throat kinematic inhibition of the quad, so the quad just.
Sort of gets inhibited and does not turn on so well, which means that you're not going to get that terminal in the extension to stick. And so treating swelling properly is a really important, and I cannot tell you how many people suffer from. Swelling in their knees, like for years after an injury. And so that is number one.
And, you know, using the swelling reduction protocol for that is the way to go. It treats it from a systemic pro, you know, uh, standpoint, restoring good lymphatic flow, decreasing limb congestion, improving vascular flow to and from the limb. So key. So then, you know in, I'll link in the show notes, the episode I talked about the swelling reduction protocol.
But the key spots are gonna be the left thoracic duct, the liver, the anterior hip, which is the proximal part of the, uh, femoral canal or the adductor canal, and then the adductor hiatus and then the lower leg. Those are the key spots of the swelling reduction protocol, so that is really important sometimes too.
What happens? Which will?
Which, okay, so if you have a lot of swelling, Oftentimes the swelling goes into like the superior patella area that is like, um, part of the joint that gets swollen, especially with excessive amounts of swelling. So post-surgical especially, or post-traumatic injury when there's swelling up there that bursa, that fat bit, that pad gets sort of, um, um, Decreases its viscosity, gets really stiff.
The articularis genu, which is the muscle that's deep to the quadricep that is there to lift up that bursa, lift up that fat pad out of the way from the patella, um, during a quad contraction, it becomes inhibited because it almost, it's almost like it gets glued down to the bone because of all the swelling in the area.
And so, This is an area that limits knee extension quite a bit because when the articularis genu is not working very well, then you have the scenario where you, when you activate the quad and go into tur terminal knee extension, the patella. Impinges, the fat pad impinges the bursa and you have pain and irritation.
This impingement can, you know, you know, obviously sends a message to the spinal cord and the nervous system like of pain. And so then the body starts to avoid using full extension and full quad activation. And so this is a pattern that I see quite often. So restoring, um, Good function of the articularis genu is so important.
Um, but then part of that too is understanding the role of the position of the patella and the position of the patella. Oftentimes, if there's been this. Sort of prolonged swelling. There tends to be often a superior migration of the patella, and so this sets up for that impingement. Quite a bit too. And so we need to look at the position.
I do this by assessing how many fingers distance between the patella tuberosity and the inferior pole of the patella. So these, this is a driver of lacking knee extension because of patella femoral joint mechanics or pain and like quad control issues. So then we also have, um, You know, I can't, I don't wanna discount to the role of the visceral organs in the knee.
Oftentimes when the knee, um, when there's a visceral organ referral to the knee is zero genital organs, specifically, often the kidney. And so we wanna make sure that the kidney is. Moving and happy and not adding to sort of these, uh, visceral protection pattern of, of knee pain or limited knee mobility.
Um, and then also from a visceral standpoint, we wanna make sure that all the nerves that are inner innovating the knee joint are free to. Move and glide and slide so they can fully function to do their part in sending messages to and from the knee joint. So, um, those nerves, it's gonna mean to be the femoral nerve.
Um, the Nerf, the um, Well, multiple branches of the femoral nerve. So there's um, Uh, branches from the main femoral nerve, but then there's also branches from the saphenous nerve. So the infra patella nerve specifically comes off the saphenous branch of the femoral nerve. And then from the posterior side, we've got, uh, branches from the tibial nerve and branches from the common peroneal nerve, so that those are a lot of nerves that we need.
To potentially treat and free up to ensure good joint mobility, good sensor information from the joint and good, uh, motor control of the muscles surrounding the joint. So I love to free those up using, um, the dynamic cupping or neural manipulation technique or fascial manipulation around this, uh, the slips of where the nerves come out or, um, dry needling.
All of those modalities work great for that. So before I would address any knee stiffness with like a joint mobilization or. For especially a forceful passive range of motion, I would make sure that I've treated all of the nerves related to that joint. The other thing that I love to do is movement with bone rhythms.
So bone rhythms is something I learned from Eric Franklin, but it's base basically embodying movement that the bones are doing from an artomatic standpoint, like embodying that. Throughout thematic range of motion. So for example, if I have somebody laying on a reformer or a shuttle, like leg pressing, just going back and forth in a squat, so like from knee flexion to knee extension, that's a great opportunity to work on these bone rhythms to facilitate more range of motion into flexion or extension and.
What's happening as the knee is flexing the um, tibia, am fibula, the lower leg as the knee is flexing, go into internal rotation, and then the femur. It goes into external rotation. This is the cool thing about bone rhythms. They alternate, right? So if the lower leg goes into internal, the one above it and the one below it goes into external.
So you only kind of have to remember one thing. So as the knee flex, the tibia and fibula move into internal rotation, the femur goes into external rotation, and then as we extend, the opposite happens, the tib. The tibia and the fibula move into external rotation, and the femur moves into internal rotation that is classically known as the screw home mechanism.
This is what creates terminal in knee extension, the muscle that helps create this rotational movement, this arthrokinematics pattern. It's a Lydia, but the shape of the joint is what creates this, right? So let me grab the bones real quick. So you can see that, that, that this, this movement, this aromatic motion is just built in to how the bones interact with each other.
So here's the tibia and here's the femur. And if we look at the tibial plateau, you see that they're, you know, um, concave surfaces and then the condyles of the femur are convex. Right, and there is a articulation happening here that is creating this rotation. See how it spins easily as well as a rolling and gliding of the bones, right?
So when we're moving into flexion, the tibia and fibula moves into enter rotation, and the femur moves into actual rotation. Now we don't see it. We don't necessarily see those aromatic motions outside the body. They're happening within the joint. All we end up seeing outside the body is this flexion and extension.
When those motions are not happening in inside, in the joint, then we see them outside the body as aberrant osteo motions. So sometimes you'll see a big internal rotation. Moment happening when there is no internal rotation happening here. Right. So that can sometimes key you into mobility that is lacking.
So the interesting thing too, when it comes to common knee injuries, the axis of rotation of this joint is the acl. So this is especially common after ACL sprains after c l surgeries to lose a lot of the rotational control around this femur and tibia. Motion, uh, because it was its original center of rotation.
So I love the bone rhythms. The bone rhythms work great. I use the bone rhythms, like I said, in like a leg press scenario and just a free body weight squat. I do it in short. Our quads can do it in quad sets. You can't do any long arc quads anytime you're working on it. I place my hand on the body part and.
Facilitate it through a really light swiping of the limb and, and you can have your patient embody the movement in their hands. You know, their hands can model the femur and the tibia and so they can be like tibia in femur out opposite tibia in femur, out, femur n tibia out, femur n, sorry, tibia n femur out, femur N tibia out.
As they're going through the range of motion, and this can be really helpful in restoring that and creating enough muscular control around the movement as needed. But as little as possible, which is so important sometimes after injury and surgery, because sometimes people are, it's stiff or they're afraid to move, and so their muscle contraction tends to be like too much or not enough.
And when you're focusing on just the bones, moving, the muscles can. Have an easier time at deciding how much tension to create is needed for the anticipated load or event. So bone rhythms are one of the best things that you can do to restore extension in a pain-free sort of way. With that said too, using that understanding of the bone rhythms and the screw home mechanisms, sometimes in the past I've done like muscle energy techniques for it though, since I've learned, you know, how to free up the nerves and the importance of freeing up the nerves and then the bone rhythms.
I tend to use that less and less like I haven't used it in years, to be honest. One of the other things that is probably not so common, Yeah. Um, well as we're talking about that, even though I showed you what's happening at the femur and the tibia, the fibula, though it doesn't articulate with that joint, still articulates with the knee joint, right?
There are ligaments that go from the proximal head of the fibula into the posterior joint capsule. They connect with the uh, meniscus, they connect with the pcl, they connect with the joint capsule itself. So knee joint, posterior capsule, posterior corner knee, joint mechanics have a lot to do with the fibula moving as well.
So again, I'll link the episode unlocking the fibula that I did because you'll wanna make sure when you're. Working on someone's knees, whether they're missing full knee flexion or full knee extension. Making sure the fibula is able to move is a big part of it because of those attachments from the knee joint to the proximal fibular head.
So, um, we've got treating the swelling. Freeing the nerves, doing the bone rhythms, unlocking the fibula, um, looking at the patellafemoral joint and the Artis genu connection. And then, um, The last couple things is the joint mobilization itself. So if you've done all of those things and you still feel like there's some knee stiffness into extension or flexion for that matter, um, and you, and you're drawn to do some sort of joint mobilization, I think it's actually best to start with a compression.
Of the joint. So joints, especially a joint like the knee, that is a, primarily a weight-bearing joint. It's love lan, love language is compression or pressure and so you can, um, create a little extra compression with your hands. I basically like set the person's foot up. On my chest, like I'm sitting at the bottom of their leg, put their foot up on my chest, their knees right here.
I put my hand on there. Um, you know, we're in like maybe 90 degrees of knee flexion, which is a fairly comfortable and safe position, even when you're lacking range of motion. And I take my other hands on the femur and I compress the femur into the tibial plateau. Into my chest on their foot and I com. I basically compress and let go compress and let go compress and let go.
The, the three times of compression let go is sort of waking up the prop receptors in the joint again, that the love language to that kind of joint is pressure, is compression and so, and again in 90 degrees of hip of knee flexion. It's fairly free to move. It's not a, you know, it's not a position that's like a closed position of the joint.
There's some, some movement that can happen. Some of that aromatic um, rotation, tibial rotation can happen. And then you have gravity that can help. Maneuver it too. And so after I do the compression, I pay attention and see what does it feel like the body wants? And you can use your whole body, your hands in the chest, and you follow where it goes.
And you'll be surprised. Sometimes you'll feel how it wants to add some internal, add some external. Sometimes it wants the whole leg to fall out to the side or on the inside, and you just follow it where. It wants to go. And oftentimes I even feel the leg coming out into, um, knee extension. And it's just a great way to facilitate, um, some improved proprioception and improved arthrokinematics in the joint that's a lot more gentle.
Um, so that's a great way. Um, I'll do that. I like that seated, seated version. Um, but then sometimes too, depending on the size of the person, I can do it in a little bit more flexion, especially if I'm working on regaining flexion. But even to regain knee extension, that flexed compression induction, it's called an induction, is when you, um, load the tissues to create a response and then you follow where the response takes you.
It's an osteopathic technique, so that works really great. Um, you, this also you can do on your own. I'll link a video I have on YouTube and it's basically like knee flexion and extension. With a kettlebell on top of it. Again, adding and compression and going through the ranges of motion is really helpful to improve the proprioception of the joint and that often facilitates better arthrokinematics, better mechanics in general, and gives you a little bit more range of motion.
Um,
Improving ankle mobility. Um, it's kind of a basic one, but ankle mobility and knee health go hand in hand. Again, like we were looking at ankle mobility in the low leg in general, the long, lower leg muscles, the deep ones, and then even the gastroc like, it, it, it, it. Affects the fibula. The fibula connects to the knee joint.
It affects the gastroc itself, crosses the knee joint, so the low leg and its soft tissue cannot be discounted in its role of good knee health and good extension. Um, and then finally, um, I like to do, like if I've done all of those things and I still feel like there's a little bit of terminal knee extension left on the table, I'll use a joint distraction cuff and I will distract the tibia from the femur and then have the patient do an active quad set or short arc quad while I'm providing.
The distraction that just creates a little bit of space so that when they activate the quad and they go into terminal knee extension, there's space for the femur and the tibia to glide and, uh, do a posterior glide. And so, um, That can be a really helpful thing too. A lot of my athletes love that, like love it, like and, but again, it sticks better when it's the last thing I do, despite them loving how it feels.
It just goes easier and sticks when I've freed up all the other things first. So, um, that's a really helpful tool as well, but, All of those things that I mentioned, like I haven't had a knee in a long time that I haven't been able to get really great full terminally knee extension for someone. And then of course, as you get the mobility with all these manual therapy things or these bone rhythms, like you gotta keep it right and you gotta, and the only way you keep it is by.
Um, strengthening your quad and strengthening your lower extremity, your hips, your quad calves, shifting your weight forward on your feet. Right? Um, so you're not, when you're, when your weight is shifted too far back on your heels, you'll hyperextend the knee and then you're never really using your quad, um, and you're kind of like hanging on the ligaments.
And so yeah, you'll have full extension, but you won't have good quad control, which means, um, The tendency for, uh, the knee to get stiff is going to be very high. So you'll want to make sure that you're correcting a lot of your strength and mechanics of the whole entire lower extremity. So, um, but those are my tricks.
I'll link the podcast episodes and the notes. I'll link the YouTube videos. That I have of the bone rhythms and the compression and, um, the Instagram posts of, um, a couple of the techniques I mentioned. And, uh, hopefully that helps. Again, thank you for the question. I really loved this question and, uh, I really, really, really hope.
That no more patients have to experience what I experienced in my knee rehab and just feel how uncomfortable it is for a practitioner to try to force motion there. Remember, the body is working for you, not against you. So if you find yourself forcing range of motion, take your hands off the patient, take a step back and.
Think about a better way to do it because there is a better way to do it that doesn't create more pain and trauma for the patient,
period. So hopefully that's helpful. Um, thanks for joining me. I'll see you next week.
