Episode 199 | Avoiding the Range of Motion Regression in ACL Rehab: Key Self-Tests for Maintenance

What is up team and welcome back to another episode on the ACL athlete Podcast. Today, we are diving into a question from an ACLer that I think is a good question: can I lose mobility after having gained it back if I start focusing more on strength? This is something that is a really good question because it’s something that people don’t think about necessarily, especially if they’ve achieved their range of motion, their extension, their flexion at the knee. And so then usually sights are set on trying to gain strength. The short answer to this question, can you lose it? Yes, you actually can. It goes back to that saying if you don’t use it, you lose it. But that doesn’t mean it’s going to regress significantly. But this is something that we do see in a large population of ACLers. There are some people who get through this and once they achieve it, they never have to worry about it again. It’s there and it’s awesome. But there is still a good chunk of people where they’re trying to regain that range of motion. Let’s say once they do that, there is something where they will start to focus on strength. 

Now, does this mean that you have to focus on one or the other range of motion or strength? No. A good ACL rehab program is usually tackling both working on a range of motion and strength. Now range of motion is a top priority post ACL injury and surgery—part of the goal of achieving a quiet knee. Especially if we’re talking about extension here, that is numero uno for us. It’s very rare that we are not saying, “Hey, extension is your number one priority.” But with this, that is going to be very important for us, apart of this quite knee, you’re also working on flexion as well. I don’t want this to seem like it’s just extension, you’re working on both. But extension does get a higher priority here. There’s less focus on loading super heavy beause you just had an ACL injury or surgery. You’re in that acute phase, you’re in that what we call protection phase. And personally for us, building out ACL framework, my four R roadmap and framework, this is our restore (phase one). This is where we are focusing hard on a quiet knee, along with some other pieces. But quiet knee is a very big goal. So that is going to be full knee extension, getting the quads active and firing alongside that knee extension so that goes hand in hand. And then getting towards 90, then 120, and then towards full flexion, that is technically a criteria for the quiet knee. And then we’re trying to get to zero levels of pain and swelling eventually in this process. 

Now, is that immediate? No, some people can vary in those two symptoms. But with that said, we want to make sure we decrease that and eliminate the pain and swelling. That’s a part of the quiet knee and in a sense, it’s just getting it quiet. We’re trying to get it back to its normal, restored state. The goal is to have none of the symptoms and have full range of motion and get the quads active. 

I’m going to also add within this first phase, is trying to get gait normalized and get the walking mechanics normalized so you’re not hobbling around or swinging the leg around and using that strength that you have incorporated with the quad work and getting the hamstrings involved, the glutes involved, the calves. But then also making sure that range of motion is coming together, the co-contractions, all the things that happen with walking that we take for granted. We want to make sure that that is worked on again.

It seems like riding a bike with walking. You just start walking again. How hard is that? But if you don’t have the requisite range of motion, if you don’t have the proper quad activation, because your quads are actually pretty active while you’re going through a gait cycle and then making sure that you are able to decrease the pain and swelling, symptoms will play into that too. Otherwise, you will work to compensate around this. That is going to be our goals after an ACL injury and surgery. 

With that said, we want to make sure that from a range of motion standpoint, some ACLers they might achieve this very quickly, especially the range of motion pieces. Some people might take a while for a number of reasons. It could be because of the injury itself, the surgery itself, the time between, people jump into surgery really quickly because the surgeon has a spot available. They aren’t educated about waiting to let the knee calm down. Maybe they are just trying to get it done because they want to get back to a certain time-sensitive thing or they’re at a good break. There are a lot of reasons why people might jump into surgery very quickly. But with that said that is something that factors into maybe their status going into the surgery. Then maybe other procedures that happened in the surgery itself, meniscus, maybe it’s an LET, maybe it is another ligament reconstruction, an MCL, there are a bunch of different things that can also happen with the injury that the surgeon might have to also help repair or do something in the knee in addition to the ACL.

Your pre-injury status also matters a lot and your fitness level prior to getting injured. Genetics play a role. There are a lot of things that can just play into a lot of the things that unfold in this process for people in terms of getting the range of motion back, dealing with pain. I mean, even thinking about work, for example, work can play a big role or school in terms of maybe symptoms and how people are on their feet more versus not. 

And then the other thing, the big one is going to be, of course, the rehab and the guidance they’re getting. That can really impact people getting range of motion back really quickly, or it might be the thing that takes a long time,  a lot of factors that play. Regardless of the time is achieved, your extension and flexion, you can lose some of it if you don’t work on it consistently. With that said, in the earlier parts of this process, you’re going really hard on this stuff and then eventually it does pull back a little bit. It’s less of a priority once you do achieve it. 

Now as I mentioned, yes, it can regress some. A good program is still working on ways to maintain this. But sometimes we work with people later and they end up saying they have it and we go to assess this and they have like maybe 90% of it, where they said they regained it, maybe they were told that zero was okay. But let’s say that some of these people, they have regained full knee extension and full flexion. When we go to assess it later in this process, when they come to us, they only have like 90% of it. What gives him this? Well, if the program shifted and didn’t have check-ins with range and solely focused on strength, for example, then that full extension or that heel pop or the flexion can regress a little bit, not drastically. It’s not like you’re going to see this massive regression. Then there might be something else going on. But let’s say it just regresses a little bit. And that little bit matters a lot, especially when we’re talking about full terminal knee extension, that impacts the pressure on the patella, the patellar tendon, the resting state of the quad. And also there is a lot of connection between not getting that full knee extension back and then more short and long-term impacts to the knee from strength all the way to osteoarthritis down the road. 

Does this mean that if you don’t have it now, and you’re far in this process that you’re doomed for that? Not necessarily. This is something that can still be worked on and achieved. But with that said, it is important to regain that terminal knee extension, it is very important. And then for flexion, for example, the importance here is, let’s say, if you like yoga and you want to sit back onto your heels and you can’t get all the way down or you got to bend over to be able to get something off the ground. Maybe you’re a teacher, maybe you have a little kid and you need to get down on the ground with them, maybe you are an Olympic weightlifter and you’ve got to get into a full squat position for general weightlifting. You would want to make sure you have access to that. 

And then let’s also talk about sprinting, for example. We need that full flexion for that heel recovery to come through and the hamstrings that kick out, in order to make sure that we can get that full cycle and sprint well.  Knee flexion does matter a lot and we want to make sure that we can get that back. Range of motion is going to be key to maintain that

Now with this, we are assuming, of course, range of motion is achieved. One thing I do want to add, we are excluding anything happening in the joint later like scar tissue, cyclops, other issues arising. Let’s just say that you’re able to gain that range of motion and then later on in the process, it regresses but there’s no barrier to it necessarily. It wasn’t focused on. If we’re assuming that range of motion has been achieved, flexion and extension matching the other side of the uninvolved side or the contralateral side, opposite to the ACL injured or operated side, then it just regresses back. We typically see this with extension more than flexion because extension is a little bit harder for people to get, especially early and flexion could linger around. It depends on the person. But there were aggression typically happens more with extension. 

How do we address this and keep an eye on it? You’re like, all right, let’s make this practical, what do I need to do? I know you’ve been talking about it, Ravi. We need to teach you and what we do for our athletes, ways to self-assess and test it. And what is the end goal? What does that look like? What does it feel like and where it needs to be? And then you can always check in on that, whether that is early post-injury, post-op, mid stages and even late stages. This is something that I teach all of my athletes and it’s something that is super important.

For knee extension, we’re going to teach athletes the heel pop test. Essentially what this is, is it’s going to check the box on terminal knee extension. So that basically means our very end range of knee extension. Our quads are active and we can get there actively. If we can do that, we check the box. With that said, what I usually do is have athletes to sit on the ground, not on carpet. We want almost like hardwood floor, not on a bed, something where there’s pretty even surface, not a lot of give to it. You’re just going to do a heel pop or basically a quad set on your uninvolved side. That heels should rise a little bit off the ground. The back of the knee is touching the floor and then you are going to have that heel rise. You can almost slide like a piece of paper or just something super thin underneath the heel and that heel should pop up off the ground for majority of athletes. Not everyone perfectly, but I would say 90% to 95% of people based on range of motion, they get a little bit of hyperextension. So what that means is when that quad contracts, it’s going to push the back of the knee into the surface that you’re on and your heel is going to slightly lift off the ground. And there’s going to be a little bit of space under your heel. That is the heal pop test. We do that on the uninvolved side to get an idea of, this is our goal. And then we have the athletes work on this on the involved side. Now there are different strategies to do this. Passively lifting up with a strap, over pressure, bag hang type stuff. There’s a lot of different strategies to work on this, but at the end of the day, that’s our goal to get the athlete back to. Once they have mastered that, then they are in a good place to just check in on that and maintain it.

For knee flexion, we teach our athletes a tall kneeling setback. Basically imagine you are on both knees and you’re standing tall on both knees. And you’re just going to sit your butt back onto your heels. Almost think of it as kind of like that yoga pose, like a child’s pose. But you’re not rocking your arms back. You can use that as a bridge if you will. And that’s the way we work on knee flexion. But the true test is to be able to be tall kneeling, standing with your head just as tall as it can be and your torso is straight, you’re on both knees on the ground. And then all you’re going to do is sit back onto your heels with your butt touching your heels. Now, does that feel normal side to side.

Often what people will feel with this, if it doesn’t feel the same, is that they’ll feel some tightness in the front of the knee like a balloon feeling. They might feel like one of their hips kind of hikes up a little bit to get into that position. They can feel kind of like less pressure on one heel versus the other, or they’re leaning to one side. A great way to look at this is you can actually video yourself from the backside and look and see, is this something where my hip hikes up or am I sitting back comfortably? And then we’re going to check in and make sure we compare side to side. 

There’s two things we want to look at. One is how does it look? For the heel pop, we’re looking, can it rise to the same height as the other side, the uninjured or uninvolved side? One caveat is someone who is hypermobile and they can get minus 15 degrees, minus 20 degrees. We might not be looking for perfectly even heel pop because we don’t need that excess heel pop. We might be just aiming for around 10 degrees minus (in the negatives). So that is going to be a very specific situation. But for 90% to 95% plus of people who are listening to this and going through it, you’re going to be aiming to match the contralateral side. And that is going to be your gold standard for this process. We’ll do that for the heel. Pop is the height of those heels, even and then I’ll have people do heal pops with both sides. 

I had an athlete the other day do this. And at first she was like, yeah, I got this. It looks the same. And then we tested it and I got her do it on her uninvolved side. And then she held it and then she did it on her uninvolved side. And she had been working on quad sets for awhile, had gone to PT,  been working through some of this stuff and exercises somewhere else. And then they come and we assess this and we’re like, we’re not all the way there yet. And she was able to feel it but also see it. And so that’s going to be really important because sometimes people think they have it. We need to make sure we do a very detailed check-in and test on this. The heel pops great for this. We’re going to look at how does it look? How does it feel? Same thing with the tall kneeling setback. 

As I mentioned, the gold standard for you is your uninvolved side. And for anyone that tells you zero degrees extension is okay. Go listen to my podcast where I talked about that. We often hear PTs or surgeons are like, “yeah, zero’s good.” And it’s like, no, it’s not. Your knee actually goes into hyperextension majority of the time, for most people. We want to make sure we regained that because that impacts the quad contraction, it impacts your gait mechanics, it also impacts like the carry over into strength and just movement in general. We want to make sure we regained that range of motion that we have access to, in order for it to carry over to other tasks we want to do.

We want to make sure that we are having checkpoints throughout the process where we’re able to assess this knee extension, knee flexion. Our athletes can check in and test it themselves. And if it regresses, we plug some work back in. Ideally, a good program that continues to keep checking in on it is what you’re working with. Now that’s where we want to make sure the athlete doesn’t need to necessarily have dedicated work. They might have to have it plugged back in if it does regress. But a good program is tackling this and this might be through triple extension type positions, needing terminal knee extension with it, or maybe triple flexion based positions. And work where it might be assisted deep squats, for example, or some sort of knee over toe type position where we’re working on it and getting comfortable, or maybe some rock backs. A lot of different ways to tackle and work on this without having to directly do this later in the process. But if we need to pull out the isolated work that we were doing immediately post-op or post-surgery, go for it to be able to regain it and then just work on maintaining it. 

The one note I did want to mention is that if you’re dealing with kind of ebbs and flows of swelling in your knee, even the slightest bit. You might not even be able to see it, but there might be some joint fluid in there. That can impact these positions and your range of motion. And that’s okay, but we want that to go away over time where it is consistently non-symptomatic, it doesn’t feel that puffiness and it’s a good environment in the knee because that will help carry over for the long term. 

But in certain scenarios, we can see where people might be getting back to some jumping and impact, maybe some running and they’re building that up, some higher intensity training, or maybe they’re building a volume and intensity back to sports and re-integrating back. Sometimes long trips can play into this, high step counts as we all know. Can influence that knee the status and the state of that knee and the puffiness and tightness is feeling. So, if you’re dealing with that, even if you’re mid and late stages, now it shouldn’t be an excessive amount of swelling, but if it feels kind of tight, especially with that tall kneeling rock back, that could be a player in this. And sometimes people will do their heel slide or pull their heel to their butt while they’re sitting. And they’re like, look, I’ve got it. And then we have them do the tall kneeling rock back, and then all of a sudden they kind of feel that tightness or discomfort. Or that last little bit that, 5% of knee flexion that just doesn’t feel right, or it feels. Feels a little stiff, if you will. Something to know for those of you who are working through this and trying to figure out, well what’s going on here. 

And of course, always talk to your medical professional, your physical therapist, your coach surgeon to check in with this stuff and see what is going on because everyone’s case is so different. But I just want to make sure that we tackle this question because it’s a good question. It’s also one where we want to make sure we check in regularly with these tests, I mentioned. There are other ones that exist. But to me, it’s simple to explain to my athletes, the heel pop test, the tall kneeling rock back and those are ones that you can regularly do to check in and see if that’s okay. 

And for us, we still assess that even in mid and late stages, just because we check the box in the earlier stages, we’re still going to look at this stuff later on. Just to make sure it is still there because we do not want to let that regress and we don’t want to leave any stone unturned. This is, of course, working alongside strength in this process. You can do both, but priorities may shift depending on where you’re at, timing wise and the phase. 

Note this, if you are somebody in this process, you just do the check-in and see, can I do the heel pop test? Can I do a tall kneeling setback or a rock back onto my heels. And assess: one, how it feels and assess how it looks? Make sure that heel pop high is even on both sides. And then make sure that the knee feels really solid when you go to setback on your heels. If it doesn’t feel the same side to side, and then therefore, maybe there needs to be some more intentional work. 

It doesn’t matter where you are in this process. We want to make sure that thing feels like the uninvolved side and that’s our goal. And that’s going to help you in the long run. I made a very long episode about how to maintain your mobility. And if you lose it, I hope that this was helpful. I want to make sure I’m as detail as possible for you guys to make sure you can understand this, understand the ins and outs of it, ways to check it and make it very practical. 

If you have any questions, you know where to find us. You can hit us up in the show notes. There are different mediums to connect with myself and the team. You can send us an email, Instagram, be able to even do fan mail through this, which is pretty awesome. Getting messages from people if you want to propose some podcast episode title, you could do that in the show notes. All the details are there. The resources people we work with and the services that we provide. If you need any help or assistance, we’re here to help support you. Until next time team, this is your host, Ravi Patel, signing off.