1) What objective measures do you use throughout to track progress?
-Quad strength (SLR – extensor lag/no lag), isometric strength (at end stages) and isokinetic (I don’t have the equipment though)
-gait kinematics (I think normalizing gait and monitoring it throughout, especially at the start of weightbearing is important)
-Functional: Squat (symmetry, depth, quality). I also read somewhere about being able to lunge with adding 1/2 body weight is a good indicator to begin running protocol. Other tests such as hop testing (single leg hop for distance, triple hop for distance, crossover hop for distance and 6-meter time hop. The general rule is to obtain an LSI ≥ 90% compared to the reference limb.)
Below is a nice article by Mike Reinold which discusses this and has some good references added in.
2) What are your go-to techniques to gain terminal knee extension and get the patient to utilize it during exercise and gait?
I tend to perform manual techniques (anterior tibiofemoral glides, superior patellar glides, etc.) first.
Passive: The exercises I go to are heel/calf props, sitting in a chair with leg propped on another chair with a gap between and using either a weight or self-applied force (LLLD has worked well for my patients). More ac
Active: SLR(can do active assist with PT, use NMES, or even march up/ecc SLR), retrowalking, sled push/pull, TKE (standing/prone), SLS, Marching.
There was an Instagram post regarding knee extension posted by prehabguys that have videos and explanations on some of these.
3) What does your HEP look like early on and as rehab progresses?
Early – Understanding of weightbearing status, proper use of crutche(s) then get rid of them as early and safe as possible. Large emphasis on knee extension (more time the better, as long as they are doing it safely and to tolerance), quad strength, and gait kinematics. I also through some heel slides in to promote knee flexion. Scar mobilization, proper wrapping and cleaning of surgical site is also taught.
*One really cool external cue that I use during squats to help equal weight shifting is to have them perform a mini-squat while standing on a wobble board with a box under the affected side. If they are weightshfiting properly the wobble board should remain relatively fixed. If they are placing more weight on the uninvolved side, the wobbleboard will..well..wobble and they will be able to see and feel the difference. A mirror works well but is not as effective through my experience.
Mid – Same as early but focusing largely on functional strengthening (wall sits, squats, continued gait, glute strengthening, hamstring strengthening, etc.) Incorporating proprioception and kinesthetics into treatment by adding in some external perturbations and changing surfaces. I tend to try and make this phase a little more fun as the first phase is kind of boring for them. During wall sits or lateral walking I’ll give them a basketball or something to dribble (more so if they are a basketball player)
Late – I make it more functional : if they are an athlete or are trying to get back into running and are ready, I may give them hopping drills, running intervals, resisted lunges, squats, etc. For other patients I may give a faster walking exercise, stairs, squats, etc.
4) How often are you seeing these patients early on and as they progress through each stage of rehab?
I think the first 2-3 weeks are crucial and if able, I like to see them 3x a week to help get the ball rolling and then drop them down to 2x a week. Once they are late enough into the game to perform activities safely in the gym (if an athlete), I may do once a week to focus on higher level activities to make sure they can perform them safely outside of the clinic.
5) Thoughts on open chain kinetic exercises?
I think they are okay for isolated strengthening when safe to perform but I think they aren’t the most functional and should be used as an adjunct more so than a main intervention.
Graft selection
I think this is very important to go over with your patient to help educate them on the graft that was utilized. I observed an ACLR and was able to watch the surgeon create the hamstring graft and talk me through the steps. One of the golden nuggets that the surgeon told me was that patients who have a hamstring graft will often describe discomfort in the medial aspect of their affected leg which may be related to the hamstring harvesting process (they really have to go up high in the leg in order to get a good amount of tendon). Knowing that has really helped me when patients have told me about their inner thigh pain and I am able to explain to them that it may be related to the graft and that it is a normal sensation to feel post-op.