“Full” vs. Symmetrical Extension S/P ACL reconstruction

Steve has struck again. Glad you made it to Wilk’s course and I’m glad that you tackled this issue. Wilk is great because he always traces things back to the facts and has several years of experience as a PT and as being Dr. Andrews right hand man. I like all of the interventions that you mentioned and there is also some research that suggests patients are more likely to have a worse outcome when symmetrical extension is not achieved. The docs should also be pulling their grafts to 90 newtons based on the work of Nicholas et al in AJSM that looked at outcomes in patients who were placed into a high and low tension group (90 & 45 N, respectively), and the high tension group had a significantly better outcome. The one thing that I will say that PATIENT EDUCATION should be at the beginning of your list!!! Otherwise you hit a homerun my friend. Look forward to catching up soon and keep up the great work.

This issue has been studied from the perspective of the potential for increased laxity by allowing symmetrical hyperextension. Don Shelbourne published a report several years ago in AJSM with KT1000 results that showed there was no increased laxity with a rehab protocol that allowed patients to achieve symmetry. The detrimental effect of having a lack of symmetry in lower extremity function far outweighs any benefit one might to “leaving them short”.

Our group’s general consensus is ensure extension to 0 degrees in the first week in attempts of avoiding ACL stump scar tissue (aka cyclops lesion), then allowing symetrical extension through exercise/actively through some of the ways mentioned above. I am personally a big fan of the extensionator because the patient has control over the amount of pressure they can tolerate. I completely agree with Mr. Johnson above, patient education should top the list. Far too often patients are instructed by hospital nurses to rest w/ a pillow under the knee for comfort, then of course they do the same at home. We become the “bad guys” for working on extension at the 1st appt. I’ve found for the few patients we can see for pre-hab, they do much better post-operatively because they have been educated on the expectations and immediate post-operative do’s and don’ts. They realize the importance of extension to 0 degrees. Thanks for a good commentary!

Symmetrical extension is important for a level pelvis and neutral spine. Asymmetrical extension certainly predisposes to lateral pelvic tilt and spinal scoliosis with associated pain syndromes.

However , if the “good” leg lacks knee extension, aiming for only the equivalent amount of knee extension in the non-operated leg may be aiming too low. The non-operated leg may be also restricted. Under- achieving on knee extension following ACL reco can lead to PFJ pathologies.

Brian, do you have a reference on that Shelbourne article? I am familiar with Shelbourne’s work emphasizing the importance of regaining extension post-op, but did not realize that he had looked at hyperextension.