In this episode, we cover why you might be walking with a limp after ACL surgery or injury. We break different factors influencing a limp, common patterns we might see, what makes up walking/gait specifically, and some practical methods to help improve your gait mechanics and get rid of your limp no matter where you are in the process.
What’s up guys, and welcome back to another episode on the ACL Athlete Podcast. Today is episode number 49, and we are in the New Year 2022. Happy New Year to all of you who are listening. Today, we are talking about a topic or actually, a question that I got from an athlete asking, why do I walk with a limp? This athlete reached out to me on social media and I figured this is a good topic to touch on as I get this question a lot. And I’ll talk to athletes on the phone, or maybe they’ll message me similar to this. And they’ll say, they’re still having a limp and why is that still happening? This is an athlete who is further into their ACL rehab, months in, but still walking with a noticeable limp.
I can’t tell you how often I hear this from athletes who reach out and ones who are months to even years out. If we kind of dive into this a little bit in terms of why this might happen or why I hear this from athletes, and especially if you’re dealing with this. What happens is in most physical therapy, that there’s a focus immediately, whether it’s post-injury or post-op especially, and there’s a focus on gait and your range of motion, and then especially if there’s a protocol being followed. After four to six weeks hit, typically it is moving on to a different part of the protocol. It’s not necessarily checking off the boxes of, okay, did you meet these prerequisites or criteria, it’s just moving along with time, and maybe you’re not on crutches anymore. What I will often hear is that the athletes told that it’d work itself out over time.
Just to let you guys know it will not a lot of the times, it will not work itself out. It’s something that our bodies are incredibly smart, they’re very adaptable, and they will learn to complete the task in however it needs to be completed. If the prerequisites are not there, and the gait training has not been done appropriately. I use gait training; walking training and gait training. Gait is the term that is used in most physical therapy and kinesiology, so they’re interchangeable. But with gait or with walking, our goal is just to get from point A to point B. Our bodies are going to figure out whatever way it’s possible to get there. And that might mean swinging your leg around, hiking your hip, bending out at your ankle, or hobbling around.
There’s so many different ways that we can compensate, if you will, with our gait and our walking. And this carries over also into running. A lot of times whenever I hear about athletes who are having a limp in their walking, then they’re usually having issues with running as well. Not always the case, but I do see that a lot because they did not meet the proper criteria and prerequisites to start walking. And then they carry that over into running, which is much more intensity. Guys, we need to learn to walk before we can run. That’s really important. We did it developmentally as kids and as babies. And so really after ACL rehab, it’s no different for us to relearn how to walk, and then that needs to transfer into relearning how to run again as well.
Why is this athlete still limping? Why does it stick around? And this is going to really depend as most answers do, but it’s going to be specific to the case and what type of surgery you had, how far you are, what kind of complications may have happened during the process, how are the different joints and how are they complying, how are the muscles, all of these different things that we’ll talk about. It’s hard to create this blanket statement, but we’ll try to condense this down into some actionable takeaways for you guys.
The thing to consider is that if your days post-op, it’s normal. If you are weeks post-op, it’s normal. You’re going to have a little bit of funky gait just because you just had carpentry work done to the knee. One, you’re dealing with pain and swelling and all of those things, but you’re also trying to get your range back and all of these different muscles working. It’s normal to do that. And it can even be normal to experience this further along in the process, even some months in. If you’re sitting here months out and you’re like, I still don’t have my normal walking, if you will, then that’s still okay. The thing that I want to stress here – and just so you guys know, I have some athletes who right now are months in and they still are not having their “normal” walking cycle. And a lot of that is because they’ve been struggling with extension or certain parts of flexion. There might be something going on with their kneecap.
And we have things in place to work on this, to make sure we are intervening and figuring out what the problem is. And to be able to make sure that we are keeping this as a priority and not just skipping over it. And that’s what’s most important. Keep this a priority until it is fully normalized for you, and it’s not an issue anymore. And that may mean working on end-range knee extension, it might be flexion, it might be mobilizing the kneecap more, it might be because the swelling is sticking around and throwing out the joint mechanics. But it is a priority until it is not. And I want to make sure we stress that because that’s what ends up happening later. Is that the protocol says, okay, we’re done with gait training, you’re off of crutches and you can somewhat walk normal. But it’s not all the way there. There still needs to be something in place to continue working on this, no matter where you are in this process.
Now, let’s get down to the reasons of why you might be limping. And just think about this, walking is a combination of different muscles, tendons, joints, and other structures moving together. Each of those muscles, tendons, and joints need to have the proper prerequisites individually to combine together, to work together to allow you to walk “normal.” These are directly going to influence your joint mechanics, how the bones and how tendons, and how the muscles all slide and move against each other to allow your knee to move and how they interact with one another.
And for this, we’re going to assume that all the other joints are good to go. You’re talking about the hip and the ankle, all the muscles surrounding those structures. We’re not too focused on those for this specific episode. We’re focused more so on the knee and the structures that are involved to help get your gait dialed in. The things that you need at the knee, and range of motion are very important. And a lot of these are going to sound a lot like the quiet knee, which are these prerequisites essentially, that are important early on post-surgery or post-injury. And these components are going to make up what we need to be able to get into proper gait and walking mechanics, so we’re not walking with a limp. If we talk about the range of motion, we need full terminal knee extension. It essentially needs to go past zero degrees. If you’re being told zero is good, that is not good. We need to get back to the way the other side was, or close to it.
Most of the time, we see people somewhere around negative 10 degrees of hyperextension, so that’s 10 degrees past zero. And that position is very important for when we have heel contact when our foot strikes the ground. We need that terminal knee extension because that position is going to allow fluid contact from the heel and the knee into the rest of the cycle. And then at the knee flexion angle that we need is roughly around 65 to 75 degrees of knee flexion. Now obviously, we are moving way past that with ACL rehab and even for gait. Obviously, the goal is to get towards 90 as quickly as possible and then slowly increase over time towards the other side and what is normal knee flexion range is. But we need at least somewhere around 65 to 75 degrees of knee flexion to have a normal gait stride in order to just go through the mechanics of it.
And then the other important piece at the knee, when we’re talking about range or mobility, is your patella which is your kneecap. And the mobility of that specific bone and how it needs to be able to kind of move along in the joint. A lot of it is sliding up and down relative to your femur and your tibia (your shin bone and your thighbone). That has a lot of influence because of your quadricep muscle and that’s connected to your patella bone, which is connected to your patella tendon, which attaches to your tibial tuberosity, which essentially think about your quads down to your tendon, and the kneecap, another tendon down to your shin bone, and that’s how it all connects. You want to make sure that that patella is mobile, that way it can glide really well in that groove as you extend and flex the knee.
Next up is your quad contraction. We know the quads are really important and it helps to create stability and it helps to support us while we’re standing, walking. And it’s a big precursor to return to sport and a lot of things down the road. Strong quad contraction early is going to be really important. And in the gait cycle itself, and when we’re walking, the eccentric strength of the quadricep muscle is going to be important. So that’s when that muscle is lengthening that is going to help us to be able to stabilize our leg during this cycle.
And then if we’re talking about other factors that play into this, typically pain, swelling, and fluid are going to be there, especially early on in this process. And if you think about there being more fluid in your joints, then you might not have the same mechanics if there was less fluid in there. It might make more sounds, it might not allow the patella to glide as well as we want to. Some pain makes you avoid certain engagement of certain muscles, especially depending on the type of graft you had. If you had a patellar or quad graft, you might avoid loading your quad or stressing it, so then that might mean that you want to swing your leg out instead of really contracting it. Pain and swelling and fluid will be an important factors early on. And even stick around for a bit depending on the pain and swelling and how your knee is doing as it gets further away from post-op.
The last piece that I want to talk about here is what we call motor control, or just our ability and our skill to use the pattern appropriately. We can learn the pattern by hiking our hips up, we can swing our legs out. But that’s why we call it gait retraining because we want to retrain how we walk. And it’s essentially like learning a new skill. Walking is a skill just like any other movement. And we have to relearn how to do this the right way. And that’s going to be through repetition and drills. This might be something that can kind of get skipped over because you’re like, oh, this is boring and I know how to walk. But this can be something that can really carry over and really help. And this might be for someone who might not have gotten the range that they wanted as quickly. And so they might have to have still continued to move on with maybe not as ideal knee extension, and then they have to relearn along the way. That’s something that I think can be important. And some of the drills that I like to do with my athletes are heel-to-toe mechanics and walking, stepping over a hurdle or a cone, some sort of constraint to force you to use your knee flexion in order to step through, looking at doing forward sideways and backward walking with and without cones.
And then gait rocker where you step through and you’re going to focus through that entire heel-to-toe pattern, stepping through and then back. There are a bunch of different ways to help with retraining and with your gait. But this all comes back to why is this happening. You can work on those things as much as you want. But if your knee extension is only at five degrees and you still need to get to close to like negative eight or 10, there’s still going to be some sort of trouble with trying to get a normal walking cycle because you just don’t have that prerequisite.
And I know that’s probably the biggest thing that I see with most athletes who come out of rehab or maybe, further along, is that they never got their full terminal knee extension, or maybe it’s even flexion. And they start to do their walking and they never had that restored so then that impacts their gait and the way that they walk. This is where working with a professional who knows how to break this down, to be able to point out potentially some of the issues that are arising from gait mechanics, then can help to take that out, let’s say, its knee extension. We work on the knee extension and then we plug that back in as it goes. And then also work in drills to make sure that that comes along with normal gait. And that’s going to be incredibly valuable to make sure that this doesn’t carry on for longer than it needs to. And that way you’re not just relying on a protocol of, okay, it’s four to six weeks, let’s move on to the next thing. It’s a priority until it’s not a priority.
This essentially walks you through a checklist and it starts with the range of motion. If you have a full terminal knee extension, that’s awesome. If you can get your knee to close to 90 degrees, then you should clear the knee flexion requirements as well. And then we’re looking at the quads, and then we’re looking at the motor pattern, and then we’re taking into account the swelling and the fluid and the pain playing a role, especially early on, which should hopefully ease up over weeks and as you get further away from surgery, to allow you to normalize your gait pattern. If you’re sitting weeks, months, or even years out, it’s not too late to work on this. You just need to work with someone who is going to be able to guide you on this and to pull out some of these specific things that need to be worked on, in order to put them back in, to normalize your gait pattern. If you have any questions on that, please reach out. I would love to help. My email is in the show notes. Hit me up. That’ll do it for today, guys.
Thank you all so much for listening. This is your host, Ravi Patel, signing off.
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